HIV-Related Public-Private Partnerships and Health Systems Strengthening

8/14/2019 HIV-Related Public-Private Partnerships and Health Systems Strengthening

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HIV-related Public-Private Partnershipsand Health Systems Strengthening


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UNAIDS/09.26E JC1721E (English original, July 2009)

Joint United Nations Programme on HIV/AIDS (UNAIDS) 2009.

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The designations employed and the presentation o the material in this publicationdo not imply the expression o any opinion whatsoever on the part o UNAIDSconcerning the legal status o any country, territory, city or area or o its authorities,or concerning the delimitation o its rontiers or boundaries.

The mention o specifc companies or o certain manu acturers products does notimply that they are endorsed or recommended by UNAIDS in pre erence to others o a similar nature that are not mentioned. Errors and omissions excepted, the names o proprietary products are distinguished by initial capital letters.

All reasonable precautions have been taken by UNAIDS to veri y the in ormationcontained in this publication. However, the published material is being distributedwithout warranty o any kind, either expressed or implied. The responsibility or theinterpretation and use o the material lies with the reader. In no event shall UNAIDSbe liable or damages arising rom its use.

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WHO Library Cataloguing-in-Publication Data

HIV-related public-private partnerships and health systems strengthening / compiledby Ute Papkalla and Gesa Kup er.

UNAIDS/09.26E / JC1721E. 1.HIV in ections education. 2.Acquired immunodefciency syndrome. 3.Delivery

o health care organization and administration. 4.Health systems plans organization and administration. 5.Intersectorial cooperation. 6.Pubic sector7.Private sector. I.UNAIDS II.Kup er, Gesa. III.Papkalla, Ute.

ISBN 978 92 9173 806 9 (NLM classifcation: WC 503.6)


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HIV-related Public-Private Partnerships andHealth Systems Strengthening


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Contents

Acknowledgements 5

Abbreviations 6

Executive summary 7

Part 1: Introduction 9

The understanding o Public-Private Partnership 10

Part 2: HIV-related public-private partnerships and their contribution to the sixbuilding blocks o health systems 11

Building block 1: contributing to e ective, accessible service delivery 11Sierra Rutile Limited: expanding health education and HIV treatment in Sierra Leone 12

Yunxi Mining Company: reaching out to at-risk workers in China 12Companies clinics as partners in rolling out HIV treatment 13North Star Foundation: the workplace as a starting point or a transnational serviceprovision in several A rican countries 13Business Coalitions: Facilitating and monitoring workplace activities 15

Building block 2: contributing to a responsive, competent and satisfed health work orce 16

SIDA-ENTREPRISES: joint public-private e orts or an educated health sta in Senegaland Burkina Faso 16Becton, Dickinson and Company: Wellness Centres to relieve the pressure on nursesin sub-Saharan A rica 17

Building block 3: contributing to a well- unctioning health in ormation system 18 Voxiva, Motorola, MTN: regular reporting via Phones or Health in Kenya, Rwandaand Tanzania 18DataDyne.org and Voda one Foundation: health surveys with EpiSurveyor 19

Building block 4: contributing to equitable access to essential medical products, vaccinesand technologies 20

Abbott Fund: laboratory support rom national to regional level in Tanzania 21Becton, Dickinson and Company: knowledge trans er and supply solutions in Uganda 23

Building block 5: contributing to sustainable health fnancing 24Mars: promotion and support o the National Health Insurance Scheme o Ghana 24PharmAccess Foundation: group insurance and risk equalization unds as models orthe private sector 26

Building block 6: contributing to good governance and competent leadership 27

Fondation Sogebank: managing Global Fund grants as Principal Recipient in Haiti 27


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Part 3: Lessons learned and recommendations 29

Lessons learned rom HIV-related Public-Private Partnerships and their e orts orhealth-system strengthening 29

Priority felds 29

Support needs 29Mutual understanding 30E fcient partnership 30New topics 30

Recommendations 31Defne the partnership surplus 31Identi y gaps, new topics and matching partnerships 31Integrate health system thinking in HIV-related partnerships 31

Facilitate policy development or public-private partnerships 31Initiate early public-private dialogue 31Promote supervision and long-term support 32Enhance private sector monitoring 32


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HIV-related Public-Private Partnerships and Health Systems Strengthening

Acknowledgements

A publication such as this can be written only froma transparent and open exchange of experiences and

ideas. Primary credit therefore goes to the manycompany representatives, health officials and develop-ment partners in recognition of their inspired effortsin making HIV-related public-private partnershipsoperational for the public good in various partsof the world. They gave their time in interviewsand a review of case studies for this documenta-tion. Numerous voices reflected on the partnershippotential between the private and the public sector:

Tiffany Atwell from Abbott, Jeff Richardson from theAbbott Fund, Christy Wistar from the Abbott Fund

Tanzania, Richard Kasesela and Olaf Hirschmannfrom the AIDS Business Coalition Tanzania, StephenGrant from the Asia Pacific Business Coalitionon AIDS, Pierre-Etienne Vannier from the AIDSBusiness Coalition in the Arab Region, RenukaGadde and Krista Thompson from Becton, Dickinsonand Company, Dhevi Kumar from Center for Disease Control, Dr. Joel Selanikio from Data Dyne,Shuma Panse from Global Business Coalition onHIV/AIDS, TB and Malaria, Patrik Silborn fromthe Global Fund, Ernest Asante from the National

Health Insurance Scheme Ghana, Dr. Francis Otieno,from the National AIDS Control Programme Kenya,Dr. Moses Joloba from the National TB LaboratoryUganda, Dr. Birgit Lampe and Dr. Holger Till fromGerman Technical Cooperation, Sabine Durier

from the International Finance Corporation, HelenMagutu from the Kenyan HIV/AIDS Private Sector

Business Council, Olusina Falana from the NigerianBusiness Coalition Against AIDS, Luke Disney fromNorth Star Foundation, Hans-Peter Wiebing fromPharmAccess Foundation, Sophie Stpanoff fromSIDA-ENTREPRISES, Dr. Emile Charles from theFondation Sogbank Haiti, Anthony Pramulratanafrom the Thai Business Coalition on AIDS, Jennifer Petersen from the Office of the US Global AIDSCoordinator, Will Warshauer from Voxiva, LakshmiSundaram and Tanya Mounier from the WorldEconomic Forum and Esther Sakala from theZambian Business Coalition on HIV and AIDS.

The technical expertise, case studies and analyticalinsights on PPPs from staff of selected cosponsors of UNAIDS and the UNAIDS Secretariat was highlyappreciated. Gratitude is expressed to: BehrouzShahandeh, Kiran Dhanapala and Kofi Amekudzifrom the International Labour Organization, EdwardVela from the World Health Organization.

Special thanks go to the UNAIDS PartnershipsDivision for commissioning this documentation inpursuit of the UNAIDS Programme Coordinating

Boards recommendation to compile best practices andlessons learnt to support and facilitate Public PrivatePartnerships with respect to their applicability for strengthening the public sector and for supporting itwith their profound reflections.


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AbbreviationsAIDS Acquired Immunodef iciency Syndrome

BD Becton, Dickinson and Company

CDC Center for Disease Control

GTZ German Technical Cooperation

HIV Human Immunodef iciency Virus

IFC International Finance Corporation

ILO International Labour Organization

MDR-TB Multi-drug resistant tuberculosis

PPP Public-private partnerships

PEPFAR Presidents Emergency Plan for AIDS Relief

TB Tuberculosis

TBCA Thai Business Coalition on AIDS

UNAIDS Joint United Nations Programme on HIV/AIDS

UNGASS United Nations General Assembly Special Session

WFP World Food Programme

WHO World Health Organization

ZBCA Zambia Business Coalition on HIV and AIDS


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This document is a response to the UNAIDSProgramme Coordinating Boards recommendation

of December 2008 to compile best practices andlessons learnt to support and facilitate Public-PrivatePartnerships with respect to their applicability for strengthening the public sector in low and middleincome countries. In terms of the HIV response themost important locus of public-private partnerships isbetween companies and public health systems.

This report focuses on the contribution of AIDS-related public-private partnerships to the six buildingblocks of health systems:

service delivery; human resources; information; medicines and technologies; financing; and leadership.

Based on a desk review and interviews conductedwith representatives of private and public organizationstakeholders as well as development partners, twelvepublic-private partnerships with a system-orientationmore than only the response to HIV and strongcollaborative relations with government institutionsin the country of implementation were identified topresent insider perspectives on catalysts and hurdleswhich may be encountered in developing collabora-tions.

A screening of private sector initiatives on AIDS hasfound that public-private partnerships with a healthsystem orientation emerge in areas where the privatepartner can combine philanthropic investment withbusiness strategy, expertise and resources and wherethis investment guarantees a surplus for the publicpartner in terms of enhanced health system structuresor capacities. This can be well achieved when it comesto service delivery, health workforce support or accessto modern technology including health informationapproaches. In contrast, public-private partenrshipsconcerned with health financing and managementsupport are rare, probably indicating the existence of barriers to the development of such partnerships thatneed to be addressed.

Despite growing international interest in a better integration of HIV programmes and health systemstrengthening, most private sector initiatives remain

focused on HIV interventions exclusively. The reviewof HIV-related public-private partnerships found that

often, companies do not yet sufficiently apply a healthsystem perspective to their activities. Both companiesand health sytems need specific support on developingsuch public-private partnerships. From the point of view of the private sector, partnersh ips would benefitfrom a clearer def inition of the public sectors interest,expectations and commitment to such collaborationand mediating structures such as business coalitionswould welcome guidance on public-private part-nerships with respect to roles and responsibilities aswell as the emerging perspective on health systemstrengthening.

Interviewees identified mutual understanding asan important precondition for the implementa-tion of efficient and successful Partnerships. Diversesettings, procedures and ethics are often expressed asopposing public and pr ivate cultures which haveto be reconciled through patient and trustful nego-tiations. The private sector at t imes lacks profoundknowledge of the complex stakeholder landscapein the HIV response and health care provision. Todevelop flourishing partnerships honest and wide-ranging dialogue to inform and secure agrement in

joint planning is essential from the very earliest stages.Such planning will of course consider issue such assustainabil ity, follow-up, and monitoring, essentialto flourishing partnerships. Health financing mecha-nisms, HIV and TB treatment and mobile healthtechnology (mHealth) are areas which are of interestto the private sector and which require further technical expertise and promotion.

From the above lessons learnt, recommendationscan be derived for UNAIDS and other organiza-tions promoting HIV-related public-private artner-ships with the motive of strengthening public healthsystems.

Carefully consider and define the partner-ship surplus for both partners

The private partner wants to reconcile philan-thropy with business strategy while the publicpartner seeks a benefit for the health system.Public-private partnerships work especially wellfor medical and communication technologycompanies, but require special promotional

efforts concerning health financing or leader-ship support.

Executive summary


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Define gaps, new topics and matchingpartnerships

The UNAIDS Secretariat and its cospon-sors should identify gaps in universal accessprovision, balance them with health system

needs, advertise the demands and search for matching partnerships between companies andgovernments.

Promote a health system thinking in al lHIV-related partnerships

The private sector should be guided to applya health system perspective to all HIV andhealth-related projects. This perspective maynot lead to further action with respect to healthsystem strengthening, but it will promote abetter understanding of the project context and

potential areas of cooperation. Facilitate policy development for public-

private partnerships

National governments should be supported bythe UNAIDS Secretariat and its cosponsorsin developing a policy f ramework for public-private partnerships

Initiate early public-private dialogue

The UNAIDS Secretariat and its cospon-sors should support private sector partners ingaining a better understanding of the localhealth system, and an analysis of potential

stakeholders and interfaces. In addition, anearly exchange on promising project ideasshould be enabled.

Support the integration of sustainablelong-tem follow-up within partnerships

In the conception phase of a public-privatepartnership, UNAIDS cosponsors as wellas other support agencies should promoteand facilitate planning for sustainability andfollow-up including the provision of resourcesand capacities.

Strengthen the reporting on public-private partnerships

The UNAIDS Secretariat should providefurther guidance to the private sector on moni-toring in line with UNGASS indicators and aspart of the national health monitoring.


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The HIV epidemic demands exceptional endeavoursfrom the public sector in middle- and low-income

countries. National health systems are overbur-dened in working to scale up HIV prevention,treatment, care and support services to reach the goalof universal access by the end of 2010 1. If universalaccess targets are reached about 6.7 mil lion peoplewill be on treatment, 70 million pregnant womenwill be screened for HIV (and treated when necessary)and 2.6 million new infections will be avertedcutting annual HIV incidence by 50 % and averting1.3 million deaths 2. An estimated US$ 17 billion for HIV-specific health services and US$ 16.7 for generalhealth system strengthening and cross cutting issues 3 will be required to meet the 2010 targets on universalaccess.

Continuous multisectoral interventionswith arenewed focus on public health systems strength-eningwith full and active participation of theprivate sector are needed. The main intersectionsbetween HIV programming and the public systeminvolve the health sector. Public-private partnershipsbetween governments and companies (in coopera-tion with additional partners such as donors, technicalagencies and nongovernmental organizations) gainnew importance in extending health services. If modern technology is adopted and coupled withvisionary leadership, solutions to the human resourcecrisis may be found, and sustainable health financingand information systems promoted to pave the way for universal access.

Over the past decade recognition of the detrimentaleffects of the HIV pandemic increased among thebusiness community 4. Companies contributions rangefrom HIV workplace programmes to philanthropicand business-oriented systemic interventions thatmake use of companies core competences and leader-ship influence. At the global, level many enterprisesgive money to international initiatives for researchand programme implementation.

Many case studies of business projects responding toHIV have been published. However, the potential of the private sector for strengthening health systems

has not yet been sufficiently explored because theinternational discussion on HIV programming has

only recently experienced a paradigm shift towards anadditional health system orientation 5. This publicationHIV-related Public Private Partnerships and Health Sector Strengthening provides an overview of potential contri-butions that AIDS-related public-private partnershipscan make in this respect. It looks specifically at inter-sections between the private and the public healthsector and presents insider views of major actors.

The publication illustrates selected AIDS-relatedpublic private partnerships under each of the sixbuilding blocks of a health system as defined by the

World Health Organization (WHO)6:

service delivery; human resources; information; medicines and technologies; financing; and leadership and governance.

The analysis focuses on lessons learnt in the coopera-tion between the sectors and points out opportuni-ties and recommendations for enhanced action. It isbased on a thorough desk review and interviews withcompany representatives and corresponding partnersfrom the public sector; in addition, key developmentpartners as well as national and international institu-tions were consulted. More than 100 HIV-relatedpublic-private partnerships have been reviewed.About 20 of these initiatives showed (a) a health-system orientation in addition to objectives focusedon HIV as well as (b) strong collaborative relationswith public-sector institutions in the country of project implementation. Twelve of these partnerships

were examined in more detail with a focus on insti-tutional collaboration. The time frame for research,the envisaged report length and the availability of contact persons were the main drivers of this selectionprocess. Sadly the selection process, a necessity inorder to keep material to a manageable length, hasmeant that some examples of good pract ice are notmentioned in this publication.

1 UNAIDS (2006 ) The Road Towards Universal Access, UNAIDS, Geneva.2 UNAIDS (2009) Letter to partners by the Executive Director Michel Sidib, UNAIDS, Geneva.3

UNAIDS (2009) What countries need: Investments needed or 2010 targets, UNAIDS, Geneva.4 WEF (2006) A Global Business Review o the Business Response to HIV/AIDS 2005-2006, WEF, Geneva.5 See or example the discussion between Roger England and Simon Collins et al, as well as articles and rapid responses o Fiona Godlee, Owen Dyer

and Niyi Awo eso in the British Medical Journal, 2007, Vol. 334 and 335.6 WHO (2007) Everybodys business. Strengthening health systems to improve health ourcomes, WHO, Geneva.

Part 1: Introduction


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The partnerships reflect country situations withhigh and moderate HIV prevalence and have beenchosen from different continents. Since the Africancontinent carries the highest HIV burden, the privatesector runs more initiatives in response to HIV inthis region. The investigation did not centre on theparticularity of interventions since this informationcan be derived from other sources and case studies.It also did not set out to quantify the health-systemimpact of the partnerships described since the analyt-ical framework for such national monitoring is inthe process of development 7. Instead, this publicationintends to encourage the reader to develop creativepartnership ideas, to learn from innovative conceptsand to become aware of collaboration catalysts andhurdles that exist between the private and the publicsector.

The understanding o Public-PrivatePartnership

The term public-private partnership has to datebeen applied to a wide range of interpretations andconcepts 8. It refers to global health initiatives of impressive magnitude 9, to partnerships of privatecompanies and development agencies 10, to businessrelations of the private sector with public organiza-tions 11 or the privatization of public services and the

public-private mix of health care provision12

.

The following analysis focuses on public-privatepartnerships in an HIV-related development context.The term partnership stands for a formal collabora-tion between partners from the public and the privatesector in the country where the partnership is imple-mented. The partnership must be characterized by aformal agreement, joint objectives, mutual contribu-tions and an interaction in partnership management.

In a narrow sense private sector refers to for-profitbusiness entities of all sizes or their philanthropicfoundations excluding not-for-profit, nongovern-mental and faith-based organizations. The termpublic sector refers to governments and governmentinstitutions 13. All private-public partnerships describedin this publication partner with a ministry or govern-ment institution in the respective country of operationof the partnership. They are formalized by some kindof contract such as a Memorandum of Understandingbetween the partners.

7 WHO (2008) Measuring health systems strengthening and trends: a toolkit or countries, WHO, Geneva. The new 2008 WHO Toolkit on monitoringhealth system strengthening provides a guideline to countries or uture integration in national. Monitoring respective private sector contributions willhave to become part o these monitoring e orts.

8 For a comprehensive discussion o various PPP types read: Nicolic IA, Maikisch H (2006) Public-Private Partnerships and collaboration in the healthsector, World Bank, Washington.

9 For a discussion o Global Health Partnerships o private sector oundations and public partners re er to: Buse K, Harmer AM (2007) Seven habits o highly e ective public-private partnership: Practice and potential, in: Soc Science and Med, Vol. 64:259-271.

10 For an understanding o PPPs as par tnerships between or-pro t corporations and donor agencies see : Beckmann S, Rai P, Alli BO, Lisk F, Mulanga C,Lavolley M, Girrbach E (2005) HIV/AIDS workplace programmes and Public-Private Partnerships (PPP) through co-investment extension o treatmentand cure into the community, ILO, Geneva.Bundesministerium r wirtscha tliche Zusammenarbeit und Entwicklung BMZ (2005) Public-private Partnerships in der deutschenEntwicklungszusammenarbeit, BMZ, Bonn. Nelson J (2001) Building Partnerships: Cooperation between the United Nations and the businesscommunity, United Nations Global Compact, New York.World Economic Forum (2007) Public-Private Partnerships in health, Geneva.

11 United Nations (2008) The United Nations and the private sector A ramework or collaboration, Global Compact O ce, New York.12 The collaboration between national governments and local health care providers is an important infuence on service delivery. Academic research

on this type o collaboration is available but only to a surprisingly limited extent. From the available literature it becomes clear that the partnershipcharacter in these collaborations is hard to de ne. It is mostly a contracting-out process leading more towards privatization than partnership. Topicssuch as quality o public and private services, adherence to national guidelines or business interests would come to the ore.Bulletin Vol. 84 o the World Health Organization is dedicated to a great ex tent to collaborations between governments and private health ser viceproviders: Evans D (2006) Using o contracting in public health, in: Bulletin of the World Health Organization , Vol. 84.IFC (2007) The business o health in A rica, IFC Health and Education Department, Washington. This report provides recommendations how a betterintegration o private health care provision can be achieved. See also Sheikh K et al (2005) Public-private partnerships or equity o access to care ortuberculosis and HIV/AIDS: lessons rom Pune, India in: Transactions of the Royal Society of Tropical Medicine and Hygiene , Vol. 100:312-320.

13 Barr DA (2007) A research protocol to evaluate the e ectiveness o public-private partnerships as a means to improve health and wel are systemsworldwide, in: Health Policy and Ethic s; Vol. 97, No.1. For this research protokoll, Barr also included non-governmental organizations that havemultilateral ormal approval rom state governments as public sector institutions.


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Building block 1: contributing to e ective,accessible service delivery

The health indicators of the Millennium DevelopmentGoals will only be achievable if populations gainaccess to high-quality health services. Access to healthservice deliveryas the desired objectivehas threedimensions, services must be:

physically available even in remote rural areas; financially affordable even to poor people;

and sufficiently attractive to be acceptable to the

public 14.

In the past, HIV programmes contributed to infra-structure improvements such as building of newhealth facilities or promotion of primary healthcare services, especially through tuberculosis case-finding and treatment. On more general grounds,the provision of antiretroviral treatment hasreduced the need for hospitalization of terminallyill patients and the incidence of opportunistic infec-tions, thereby easing the load on health services 15.

For most companies, the workplace is the mostimportant access point for any kind of servicedelivery with respect to HIV because employeesare the backbone of businesses and economies 16.Workplace programmes often provide preven-tion, treatment, care and support for employeesand potentially their dependents 17. Bigger, oftenmultinational, companies also support surroundingcommunities or suppliers and have a significantshare in providing health information and other services18. The private sector widens the coverageof health information and nurtures treatmentaccess, but rarely in a systematic partnership withthe public system.

Companies often start planning and implementingworkplace interventions internally, or with specificpartners rather than with the public sector. Lakshmi

Sundaram, Associate Director of the World EconomicForums Global Health Initiative says: Employers arepragmatic. In terms of HIV action at the workplacethey often expand programmes gradually according totheir needs and those of their employees and depen-dents. But addressing gaps in the health systems iscomplex and complicatedthe reason why manycompanies shy away from this task. But not allasthe following case studies show.

14 WHO (2008) Toolkit on monitoring health systems strengthening: Service delivery, WHO, Geneva.15 Yu D et al (2008) Investment in HIV/AIDS programmes: Does it help to strengthen health systems in developing countries? In: Globalization and Health,

Vol. 4, No.8.16 GTZ (2004) Challenging Partnerships: GTZ and Private Sector Commitment to the Fight Against HIV/AIDS at the Workplace in A rica, GTZ, Eschborn.17 World Economic Forum (2006) Business and HIV: A Healthier Partnership? A Global Review o the Business Response to HIV/AIDS2005-2006, WEF,

Geneva.18 GTZ/Global Business Coalition against AIDS, Tuberculosis and Malaria (2005) Making Co-Investment a Reality, GTZ, Eschborn.

Miners knock o rom their morning shi t work on the mine.Photo: UNAIDS/L.Gubb

Part 2: HIV-related public-private partnershipsand their contribution to the six building blockso health systems


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Sierra Rutile Limited: expanding healtheducation and HIV treatment in Sierra Leone

An efficient facilitator of public-privater partnershipsis the International Labour Organization, whichgenerally works with a tripartite constituency

consisting of government representatives, employersand union members. Thus we secure from thebeginning that workplace programmes are truepublic-private partnerships, says Behrouz Shahandeh,the Senior Technical Advisor at the InternationalLabour Organization on HIV and AIDS. He explainsthat action by the Organization is centered onenterprise-level interventions to reach workers toovercome discrimination, reduce risk behaviours andfacilitate access to treatment, care and support. Incollaboration with ministries of labour, and employers

and workers organizations, enterprises are providedwith technical advice, training and material supportin developing policies and programmes. Withinthe framework of a public-private-partnership,enterprises, in turn, contribute work hours for HIVactivities, venues for training, communication andtraining materials as well as strengthening their healthfacilities or establishing partnerships for referrals tocommunity-based services. An HIV programme inthe mining sector of Sierra Leone for example startedwith a Memorandum of Understanding between themining company Sierra Rutile Limited as employer,the United Mine Workers Union and the NationalHIV/AIDS Secretariat as the coordinating body of theHIV response in the country.

In its post-conflict situation, Sierra Leone has recentlydeveloped a f irst strategic plan on HIV/AIDS for 20062010 19. The International Labour Organizationsupported cooperation of Sierra Rutile Limited,the Union and the National HIV/AIDS Secretariattargeted objectives beyond the company scope,such as a mining-sector policy and health servicesreaching out to communities. Major components of the programme are devlopment of understandingabout HIV among mine workers, health care staff and community leaders as well as the establishment of testing and treatment services in the company clinicincluding prevention of mother-to-child transmissionof HIV. While the company provides its clinic andstaff, the government supplies condoms, antiretroviraldrugs and test-kits and supports the clinic techni-cally. The United Mine Workers Union educatesand mobilizes the workers and the community. In

addition to health education and improved accessto HIV testing and treatment in a remote area of Sierra Leone, the cooperation under InternationalLabour Organization leadership has brought about aNational Workplace Policy for the mining sector inthe country.

Yunxi Mining Company: reaching out to at-riskworkers in China

Setting up a sustainable public-private partner-ship was the goal of the first major workplaceprogramme in the Peoples Republic of China whichthe International Labour Organization initiated andpromoted with support of the Chinese Ministry of Human Resources and Social Security with seedfunds from the United States Department of Labour.

The workers of the Yunxi Mining Company faceelevated risk of exposure to HIV since YunnanProvince in South West China sees 80 % of Chinasdrug traffic passing through, leading to high levels of drug use often associated with commercial sex work.This mix is reflected in rising prevalences of HIV andother sexually transmitted infections in the region 20 .Qualitat ive research conducted by ILO showedextremely low levels of HIV awareness, knowledge of services and condom use among the miners.

To tackle HIV among the Geiju mining popula-

tion a range of partners joined hands in the partner-ship including the public institutions Geiju Center for Disease Control, and the China Family PlanningAssociation as well as a nongovernmental organizationcalled Humana People to People. The internationalmedia company McCann Healthcare and the localmedia companies Geijiu TV and Gejiu Daily Newscontributed in-kind and financial resources to ensurea well integrated communication campaign to supportthe programme. The national and provincial labour departments were indispensible for advocating and

coordinating the joint activities and contributions of the various partners.

On the policy front, the Ministry and its Departmentof Human Resources and Social Security were keystakeholders in enforcing the National EmploymentPromotion Law 2008 reducing discrimination for people living with HIV. A company policy at Yunxiended mandatory testing and guarantees employ-ment rights for HIV positive workers in line with thenational law.

19 UNAIDS website (2009) AIDS responses in post-confict Sierra Leone, available at www.unaids.org, accessed 16 th April 2009.20 Guowei, D (2007). HIV-1 and STIs prevalence and risk actors among miners and emale sex workers in the mining areas o Gejiu, Yunnan, China.

Programme and abstracts of the 4th IAS Conference on HIV Pathogenesis, Treatment and Prevention , July 22-25, 2007: Sydney, Australia. AbstractMOAC105.Also see: Xu JJ, Wang N, Lu L, Pu Y, Zhang GL, Wong M, Wu ZL, Zheng & Xi Wen. (2008) . HIV and STIs in clients and emale sex workers in miningregions o Gejiu City, China. Sexually Transmitted Diseases , 35(6) June, 558-565.


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To support the provision of comprehensive preventionand care services, a professional communicationstrategy was developed to spread key messagesabout HIV-related services utilizing an overarchingconceptual theme of migrant workers solidarityand mutual support. Comprehensive capacity wasdeveloped, and peer educators, with participation of the union, integrated HIV into routine occupationalhealth and safety trainings. A company-fundeddrop-in centre run in partnership with a localnongovernmental organization provides resourceson HIV, family planning, and drug dependence. Areferral system links the miners up with voluntarycounselling and testing, treatment of sexuallytransmitted infections, antiretroviral therapy, opioidsubstitution therapy and other serv ices of the GeijuCenter for Disease Control. In 2009, an evaluation

wil l access the programmes success comparedwith base-line data collected in early 2007. Thepartnership has helped us to scale up our responseand work through company structures to preventinfections among an important risk population thathad not previously been accessible, concludes Pu Yi,Director of the Geiju Centre for Disease Control.

Companies clinics as partners in rolling out HIVtreatment

Provision of antiretroviral treatment as part of aworkplace programme pushes the private sector closer into cooperation with government. This is the caseespecially for bigger companies operating in regionswith high HIV prevalence 21.

Small and medium-sized enterprises often do not havethe financial means to provide antiretroviral therapyand relylike companies in low prevalence coun-trieson the public health system for the provision of treatment.

In certain circumstances, the private sector is

supplementing lim ited public capacities in healthcare provision with their own clinics. This isespecially the case in remote areas and amongindustries operating in isolated sites such as miningor agrobusiness. Here, companies benefit from aclear partnership with government giving themaccess to free antiretroviral drugs and other medicalproducts. Like Ok Tedi Mine Ltd. in Papua-New

Guinea nuumerous other companies now providetreatment for sexually transmitted diseases andantiretroviral therapy to keep HIV-infected staff and community members healthy, to promoteconfidence and to dry out the swamp of stigmaand discrimination 22 . Many of them such as thetea growing branch of the multinational companyUnilever in Tanzania and Kenya 23 or the cementproducing daughter company of Lafarge, HimaCement in Uganda 24 are part of country proposalsto the Global Fund and have been accredited as careand treatment centres by their respective Ministriesof Health making them part of the nationaltreatment policy.

While considerable, sufficient progress has not yetbeen made in terms of access to first-line antiret-roviral treatment, and the demand for second- andthird-line drugs is rising globally. Second-lineantiretroviral treatment and treatment of multidrugresistant tuberculosis (MDR-TB) are new challengeslying ahead of companies and public health authoritiesin the near future, says Sabine Durier, Leader of theIFC Against AIDS Programme of the InternationalFinance Corporation. Those treatments will comewith greater costs for companies and ministries of health. In her perspective, insurance mechanismsmust be created to respond to these rising costs or topotentially lower financial liabilities of the privatesector induced by the current global economic crisis.

North Star Foundation: the workplace asa starting point or a transnational serviceprovision in several A rican countries

Mobile populations have been identified as beingat elevated risk of exposure to HIV since the late1980s25. In the last decade it has been observed thatprogramme planners and implementers have madegreater efforts to address the links between mobility

and HIV. Many members of mobile populat ionsare more vulnerable to health risks and less able tocope with infections given the difficulty of accessingmedical support away from their homes. Althougha growing number of mobile workers are travellingregularly to and fro across borders, high quality healthservice delivery remains a challenge that has not beenmet suff iciently.

21 World Economic Forum (2006) Business and HIV: A Healthier Partnership? A Global Review o the Business Response to HIV/AIDS2005-2006, WEF,Geneva.

22 UNAIDS (2005) Access to treatment in the private sector workplace, UNAIDS, Geneva.

23 World Economic Forum (2007) Case study: Unilever Kenya, WEF, Geneva.24 World Economic Forum (2007) Case study o Hima Cement in Uganda Leveraging private sector resources or communit y AIDS treatment, WEF,

Geneva. This case study nicely describes the process o accreditation and contributions o various partners in extending a company treatmentprogramme to the surrounding communities.

25 Carswell JW, Lloyd G, Howells J (1989) Prevalence o HIV-1 in East A rican lorry drivers, in: AIDS, 1989, Vol. 3 No. 11:759-761.


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North Star Foundation is an industry platform of the transport sector responding to the impact of theAIDS epidemic. It was created in 2006 out of coop-eration between the Dutch transport company TNTand the World Food Programme with support of the International Transport Workers Federation andUNAIDS. North Star envisaged either strengtheningexisting health service providers or establishing newhealth service facilities in strategic points along thetransport routes, which are often hotspots character-ized by commercial sex work and high communityinteraction including occasional transactional sex.

Now North Star Foundation has grown to be analliance looking into HIV, TB, Malaria and other infectious diseases, says Luke Disney, Director of North Star Foundation. The currently eight WellnessCentres created along transport routes in by nowseven African countries provide all kinds of support totruck drivers, sex workers and community members,including hypertension control the most commondisease condition affecting long-distance truckers.

With the establishment of Wellness Centres for longdistance truck drivers, North Star Foundation leftprivate sector ground to enter the public health sector in African countries. Many lessons were learnedin taking this step. The scope of stakeholders inthe provision of health and HIV-related services inlow- and middle-income countries is huge and their influence on the national health system is substantial.Disney remembers: In Zambia we had a situation inwhich we had the support of many key stakeholders,including the Ministry of Health, but we neglected toproperly consult other nongovernmental organizationsthat were already operating in the area where we weregoing to open our new WellnessCentre. An agreement with allpartners under the leadership of the National AIDS Council wasneeded to resolve the issue of

potentially overlapping serviceprovision. It would have helpedus to have a better understandingof relevant stakeholders in theforefront, concludes the NorthStar director.

Endurance is as important asa stakeholder analysis of thenational public health arena.Collaboration with the publicsector and a good integration of

an initiative into national plansrequire time, is Disneys secondlesson. The usual fast speed of business transactions has to yield

to patience and thorough negotiations. The pr ivatesector can benefit from the vast experience of our health specialists, recommends Dr. Francis Ot ienofrom the Kenyan National AIDS Control Programme,who is Medical Officer in Charge of ComprehensiveCare Services in the Coast Province and North Starscooperating partner in setting up a Wellness Centre inthe port of Mombasa. We are very well trained andup-to-date on medical issues. In addition, we knowall aspects of the system, are adept to improvising andcan provide guidance on clinic set-up and patientmanagement.

From the point of view of North Star Foundation,the public sector can get the most out of public-private partnerships by having a clear and practicalstrategy for dealing with the private sector. It worksbest when health officials are out-spoken about their expectations from the private sector and their owncontributions to a partnership. On the other hand,companies need to acknowledge the legitimate roleof the government as the architect and manager of healthcare systems, and not simply regard them as justanother stakeholder.

Too often the relationship is seen by both sidesas a one-way-street to achieving their own ends.Dr. Otieno recommends: A partnership with theprivate sector works best, if the private partner consults with government before he puts anything onthe ground. We can discuss potential areas of conflictand f ind solutions before problems occur. Long-termpartnership is like a marriagerequiring continuousdiscourse, compromises at times and always the goodwill to stay together in a project. The most recentWellness Centre opened in the port of Mombasa in

On the Zambia-Tanzania highway, peer education programmes have been set up or truckers. The stickeron this truck reads, Condoms prevent AIDS.

Photo: WHO/UNAIDS/L.Gubb


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March 2009 is a good example. While the govern-ment supplies members of staff and medical productsto the Centre, North Star provides a coordinator whointegrates the Mombasa Centre into the remainingWellness Centre network. Clearly defined rolesand responsibilities will remove room for friction,is Dr. Otienos lesson learned af ter the f irst weeks of operation.

Business Coalitions: Facilitating andmonitoring workplace activities

As much as company workplaceprogrammes differ in scope, they veryoften have one thing in common: theyare business-tailored, but more or lessisolated interventions. As an example,

94% of African governments havereported on the UNGASS indicators in2008 26 , but none of the reports containdata reporting on the company contri-bution to treatment or prevention. Inmany countries, companies have createdbusiness coalitions as coordinatingand mediating bodies. Many of thebusiness coalitions against AIDS are actively involvedin public-private partnerships helping companiespermeating their programmes to their suppliers as inNigeria or Kenya, establishing services in remote agri-cultural settings as in Tanzania or initiating mobileconfidential voluntary counselling and testing andantiretroviral therpay provision as in Zambia to name

just a few 27. The Global Business Coalition on HIV/AIDS, TB and Malaria has started to facilitate collec-tive action projects, also known as Impact Initiativeswhich bring together several companies acrossdifferent industries with key public stakeholders. InKenya for example, the Coalition recently launchedan initiative to bring home counselling and testing totwo million Kenyans.

PPPs are very useful in bridging gaps or reducingcongestion in the provision of serv ices, says Esther Sakala, Executive Director of the Zambia BusinessCoalition on HIV and AIDS. Yet, she also identi-fies the need for relevant capacity building in theprivate and public sector. As supportive institutionspan-continental business coalitions have been createdin the Asia-Pacific, Caribbean, Arab and Africanregions. They are important bodies to sensitize

national business coalitions for the interface betweenthe private and the public sector, says Dr. BirgitLampe who is heading a regional project on businessand AIDS in German Technical Cooperation. Asin the international discussion the trend is movingtowards a stronger integration of AIDS into healthsystems, there is a need for the business sector to open

26 UNAIDS website (2009) Much progress to report: UNGASS 2008, available at http://www.unaids.org, accessed 17th April 2009. The indicators o theUnited Nations General Assembly (UNGASS indicators) were developed in compliance with the Declaration o Commitment on HIV/AIDS signed byUN member states in 20 01.

27 Data rom interviews with the Executive Directors o various Business Coalitions against AIDS: Stephen Grant (Asia Paci c Business Coalition on AIDS),Helen Magutu (Kenyan HIV/AIDS Private Sector Business Council), Olusina Falana (Nigerian Business Coalition Against AIDS), Richard Kasesela (AIDSBusiness Coalition Tanzania), Anthony Pramualratana (Thai Business Coalition on AIDS), Esther Sakala (Zambian Business Coalition on HIV and AIDS).

Home-based counselling and testing through the GBC-AMPATH Health atHome/Kenya Impact Initiative.Photo: UNAIDS/Craig Bender.

up towards a health promotion model. According to

Lampe, business coalitions need the skills to lead anddirect the private sector accordingly in their respectivecountries.

Jane Wilson, UNAIDS Regional Advisor in Asiaobserves: The role of the pr ivate sector needs tobe more integrated into the national response andmonitoring and evaluation. The Thai BusinessCoalition on AIDS takes a leading role in filling thisgap. As sub-recipient of two Global Fund grants, theCoalition promoted the development of an evaluationand accreditation scheme with minimum standards

for HIV workplace programmes called the AIDSResponse Standard Organization and is now in theprocess of developing a monitoring support structurefor the private sector to oversee company treatmentservices for TB patients and those co-infected withHIV. Furthermore, an accreditation mechanismis being institutionalized that certifies businessesproviding prevention, treatment and care services for TB and HIV.


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This can only be realized inclose collaboration with theMinistry of Labour and theMinistry of Public Health.While TBCA assesses

and monitors companiesworkplace programmes, theaccreditation is the task of theMinistry, explains AnthonyPramualratana, ExecutiveDirector of The Thai BusinessCoalition on AIDS. As amember of the CountryCoordinating Mechanism of Global Fund and the NationalAIDS Commission, theCoalition is responsible for the UNGASS reporting onworkplace issues. In the 2008Progress Report, the AIDSResponse Standard Organization tool received recog-nition as a best practice providing monitoring data onan improved protection of workers rights, increasednumber of workplace programmes, and reduction of stigma and discrimination in the workplace 28 .

Building block 2: contributing to aresponsive, competent and satisfed healthwork orce

High-quality service delivery requires a responsive,competent health work force satisfied with its profes-sional identity and workplace conditions. Humanresources for health include clinical staff as well asmanagement and support staff. Many countries havea severe shortage of health workers for reasons such asinsufficient production of new staff, in-country, out-migration, inefficient and inappropriate deployment,poor mix of skills and demographic imbalances 29.

WHO estimates that there is at least a total shortfall of 4 250 000 health workers who are currently neededin service delivery and management in African andAsian countries 30 . Many health workers migratefirst from rural areas to the cities, then to indus-trialized countries which offer better salaries andworking conditions, more job satisfaction and career opportunities as well as good quality management 31.Comprehensive, reliable and timely information onthe health workforce situation is needed to enable

targeted action, such as training of new and skill-building of experienced staff, incentives for workersin unattractive worksites, appropriate staff distribu-tion accounting for cultural specifics of populations or human resource initiatives that create motivation andpromote job satisfaction.

The private sectorspecifically companiesoperating in the field of pharmaceuticals and

medical technologyinvests considerable resourcesand competences in leveraging know-how andstandardized practices in low- and middle-incomecountries. To them efficient health systems andcompetent health personnel form the market for their products and create an environment for development.But also companies without a health focus benefitfrom competent health staff in their own productionsites or in the public system. Selected examples of public-private partnerships range from training of professionals to fostering exhausted and overburdenedstaff as the following examples show.

SIDA-ENTREPRISES: joint public-private e ortsor an educated health sta in Senegal and

Burkina Faso

Since 2008 SIDA-ENTREPRISES, a coalition of mainly French businesses runs training programmes

jointly with two national HIV programmes inWestern Africa. Twenty companies with 43 healthworkers in Burkina Faso and 25 companies with 75

28 National AIDS Prevention and Alleviation Committee (2008) UNGASS Country Progress Report Thailand, Bangkok.29 WHO (2008) Toolkit or monitoring health systems strengthening: human resources or health, WHO, Geneva.30 WHO (2006) The global shortage o health workers and ist impact, Factsheet No. 302, WHO, Geneva.31 WHO (2006) Migration o health workers, Factsheet No. 301, WHO, Geneva.

A Peer Health Education session in the Tea Plantation o Kibena, where the AIDS Business Coali tion Tanzania

is the implementer or a public-pr ivate partnership ( Comprehensive HIV/Aids Control in the Tanzanian TeaIndustry) between German technical Cooperation (GTZ), three Tea Companies and the Business Coalition.Photo: UNAIDS/ AIDS Business Coalition Tanzania


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health workers in Senegal participate in the three year activity. The modules cover basic knowledge on HIVand prevention at the workplace, legal, discriminationand gender issues, practical trainings in health facili-ties, as well as modules on adherence to antiretroviraltreatment and side-effects of drugs. After the three

year training course doctors and nurses are equippedto link workers up with care and treatment specialistsand to manage patients on antiretroviral drugs.

In Burkina Faso only 25% of the enrolled healthworkers are employees of a company, 75% workfor the Office de Sant des Travailleurs, which alsoruns two public clinics providing services specifi-cally for workers. The director of the Office is partof the steering group of the programme which is alsosupported by the International Labour Organization.The National AIDS Control Programmes of both countries contribute expertise to the initia-tive; the Senegalese Comit National de Luttecontre le sida even provides some additional funds.Sophie Stpanoff, Development Director of SIDA-ENTREPRISES, explains the strong involvementof the public sector in the training. It was quitelegitimate to ask the public sector for help for thetrain ing of health workers. She sees a big advantagein running the training in close cooperation withgovernment: The private sector needs long-termsupport on health issues and the public sector has to

guarantee this in a long-term perspective.

Becton, Dickinson and Company: WellnessCentres to relieve the pressure on nurses insub-Saharan A rica

This innovative project initiatedby the International Council of Nurses in 2006 and supported byBecton, Dickinson and Company incollaboration with various nationalgovernments and PEPFAR estab-lished Wellness Centres for health-care workers and their families asan incentive for African nurses tostay in their jobs and in their homecountries.

Wellness Centres are a symbol andinstrument of care for demoralizedhealth workers. They offer confi-dential voluntary counselling andtesting, treatment for HIV and tuber-culosis, post-exposure prophylaxisand prevention of mother-to-child

transmission services. In addition, health workerscan learn about stress management and occupationalsafety, take up training opportunities, and can findother resources for continuous professional develop-ment 32. Says Renuka Gadde: Healthcare workers areintegral partners and customers for Becton, Dickinsonand Company. For many years, the Company has beenmanufacturing products and providing services thathelp protect healthcare workers. Therefore, the ideaof working on wellness initiatives for health workerswas a natural fit for us. Through our collaborationon wellness centres, we hope to provide training andeducation and upgrade clinical practices in places whereit is most needed.

The first public partner in this project was theGovernment of Swaziland. Project outcomes inthe Kingdom of Swaziland are impressive: 77 % of the Swazi health workforce has benefited from theWellness Centre to date with a continuous increase of uptake of services. The Ministry of Health has inte-grated wellness into the national personnel policy andprovides the Centre with medical supplies as well asother support, explains Renuka Gadde, Director of Global Health at Becton, Dickinson and Company.National buy-in and ownership is crucial with respectto sustainability of the wellness centres. A projectwhich is part of a national approach has better chancesfor continuous funding from public and private sources.

The Swaziland Wellness Centre project has becomea model in the region: Lesotho, Zambia, Malawiand Uganda have opened or are in the process of

32 Baleta A (2008) Swaziland nurses the wellbeing o its health workers, in: Lancet, Vol. 371.

Photo : UNAIDS/ Becton, Dickinson and Company


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establishing similar centres. The Partnership facili-tates peer visits as an instrument to create interest of other countries in this model. It is much easier tocooperate with national governments if you have notonly an idea to present but something practical toshow as well, Gadde concludes.

Building block 3: contributing to a well-unctioning health in ormation system

Sound decision-making in health care provisionrequires comprehensive information. Data must begenerated and compiled, analysed and synthesized.Data analyses must be communicated and used aspreconditions for planning and managing of thehealth system 33. This principle also extends to datagenerated by stakeholders other than the publicsystem. It creates legitimate expectations to all other health services and activities operating in a country.Major information categories that are requiredfor planning and decision-making include data onsocial determinants, inequalities and contextualenvironments of health in the system, quantitative andqualitative data on inputs to the system and outputsrelating to services and other components as well ashealth outcome data. All this information has to bemade available in a format that can be used by manydifferent professionals.

The United Nations General Assembly Special Sessionon HIV/AIDS indicators are a groundbreakingachievement in providing comparable report ing onnational AIDS situations. However, national healthinformation systems are often burdened by parallelreporting requirements of major donor programmesresponding to AIDS 34 . Modern technology nowopens new opportunities to facilitate health reportingincluding AIDS monitoring. The explosive growthof mobile networks globally has the potential toovercome the disadvantages of remote and resource-poor environments, relieve the shortage of healthworkers and support the management of servicedelivery and emergencies 35.

The private sector plays an important role asdeveloper and promoter of in formation technology.The application of information technology in healthis called mHealth and defined as the use of short-range, portable electronic devices for mobile datacommunication over a cellular network 36 . For somespecialists mHealth will lead to a review of healthcare financing and delivery, blurring the boundariesbetween professional medical help and do-it-yourself medicine 37. Others stress the usefulness of mHealthin the management of the double disease burden of communicable and non-communicable diseases, thecost containing effect of commodity purchases viainternet with more competition and client empower-ment, and the applicability in skills enhancement of health workers 38 .

Voxiva, Motorola, MTN: regular reporting viaPhones or Health in Kenya, Rwanda andTanzania

Phones for Health is a partnership between the health-care software provider Voxiva, the phone producer Motorola, the telecom company MTN, the GSMADevelopment Fund, PEPFAR, CDC Foundation,Accenture Development Partnerships and var iousgovernments. Voxiva developed a software applicationthat integrates with core health applications and thatcan be downloaded to a wide range of mobile phones.A health worker with this software on the phone caninput health data and transfer them to a central database where the data can be analysed. In addition,the health worker can order medicines, send alerts,download guidelines, or access training materials 39.

Phones for Health is a fur ther development of theTRACnet system, which supports the monitoring of the National AIDS Control Programme of Rwandasince 2004. The system enables practitioners tomonitor antirretoviral drug stocks in real time, andaccelerates the return of results from CD4 moleculeand viral load tests to remote facilities 40 . After three

years in operation, TRACnet now covers all healthfacilities offering antiretroviral therapy in Rwanda

33 WHO (2008) Toolkit or monitoring health systems strengthening:health in ormation systems, WHO, Geneva.34 Yu D et al (2008) Investment in HIV/AIDS programmes: Does it help to strengthen health systems in developing countries? In: Globalization and Health,

Vol. 4, No.8.35 Vital Wave Consulting (2009) mHealth or development The opportunity or mobile technology in health care in the developing world, UN

Foundation-Voda one Foundation Partnership, Washington and Berkshire.36 Kahn JG, Yang J, Kahn JS (2008) The relationship among economic development, health, and the potential roles o mHealth. Presentation at the

con erence series Making the eHealth Connection: Global Partnerships, Local Solutions, conducted at the Rocke eller Foundations Bellagio Center inBellagio, Italy rom July 13 to August 8, 2008, available at http://ehealth-connection.org (Accessed 30th March 09).

37 Mishra S, Singh IP (2008) mHealth: A developing country perspective. Presentation at the con erence series Making the eHealth Connection: Global

Partnerships, Local Solutions, conducted at the Rocke eller Foundations Bellagio Center in Bellagio, Italy rom July 13 to August 8, 2008, available athttp://ehealth-connection.org (Accessed 30th March 09).38 Kahn JG, Yang J, Kahn JS (2008).39 GSMA (2007) Phones or Health Case study, GSMA, London, available at www.gsmworld.com (Accessed 30th March 2009).40 United Nations (2008) Innovation or sustainable development local case studies rom A rica, UN Dept. O Economics and Social A airs, New York.


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and all patients on antiretroviral therapy. Healthworkers submit monthly indicator reports and weeklyconsumables reports via a toll-free number. Sincemost individuals own a phone they are also used tousing text messaging features 41.

With Phones for Health we are replicating andimproving our experiences with TRACnet, says WillWarshauer, Executive Vice President of Voxiva. Webuild systems which are owned and operated by thepartner governments. The partnership has contrac-tual arrangements with the governments of Kenya,Tanzania and Ruanda. Local steering committeeschaired by senior officers of the Ministries of Healthdefine the priorities and prepare existing processesfor mHealth application. Kenya wants a listing andregular basic reporting of all public and private healthfacilities. In addition, national vaccination and diseaseoutbreak reporting will be done via mobile tech-nology. The Kenyan Ministry consolidated down 52reporting forms to one for mobile reporting of basicindicators to 80 % concerned with HIV of all publicand private health facilities in the country. Tanzaniaintends to monitor and advertise blood donation viamobile phones. Rwanda aims at a better reportingof its 50 000 community health workers and animproved knowledge transfer.

The specific needs and wishes of individualgovernments complicate the development of mHealthapplications for open source utilization. Governmentsinsist on customized solutions suiting their processesand existing instruments, says Warshauer. Part of theproject funds have therefore to be spent on softwarelicenses. Continuous need for IT-support is another threat to sustainabil ity. The Voxiva Executive VicePresident acknowledges the justi fied resentmentsof governments towards short-term public-privatepartnerships which may cut the support too early. Heassures: The Phones for Health partnership providesa national system. There is evidence that over time

governments take on more and more parts of thesystem.

In the various countries, the partnership has supportfrom offices of CDC to liaise with the nationalgovernments, explains Dhevi Kumar from the CDCFoundation. To Will Warshauer further support wouldbe welcome, especially with respect to promotingmHealth among sceptical Ministr ies of Health. Manygovernment officials do not yet see the benefits of using mobile phones for reporting in real time.

DataDyne.org and Voda one Foundation: healthsurveys with EpiSurveyor

Apart from regular reporting, surveys are anadditional tool of national health monitoring. For conducting health surveys the non-profit software

provider DataDyne.org developed EpiSurveyor,an open-source software application available toevery internet user at no cost. Surveys with datacollection on paper even with computer analysis arecumbersome; supportive internet and mobile phonetechnology exists but requires the support of experts.Specialists and consultants who have to be hired for surveys are a bottle neck for progress in resource-limited settings, says Dr. Joel Selanikio, Director of DataDyne.

Until recently, EpiSurveyor ran solely on Personal

Digital Assistants (PDAs): the EpiSurveyor softwarehad to be downloaded to a computer to create theforms for a survey. The form was then transferredto the Personal Digital Assistant and used for datacollection, and the data sent back to the computer for analysis. A new beta-version is now availableallowing the creation of forms on an internet platformwhich can then be downloaded to standard mobilephones running Java. Data collected will directly besent to the internet platform for analysis. No instal-lation of software is needed on the desktop or laptop

computersa great advantage in countries with slowinternet connection.

41 Voxiva (2008) Rwanda TRACnet Case study, Voxiva, Washington.

Phones or Health.Photo: PEPFAR

Dr. Selanikio underlines another advantage of theweb-based EpiSurveyor: We want to promote simplesharing of survey forms and technical expertise.Experts who have done HIV-related investigationscan share their surveys used for knowledge screening,behaviour change monitoring or treatment supervision.

With support of the mHealth Alliance, formed bythe Rockefeller Foundation, the United NationsFoundation and Vodafone Foundation, the PersonalDigital Assistant-based EpiSurveyor was piloted in


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Burkina Faso, Kenya and Zambia in cooperation withthe respective Ministries of Health and subsequentlyrolled out to 13 sub-Saharan African countries. Thatrollout is now being switched over to the web- and

mobile-phone-based version, which has just beentested in a nationwide child health week campaignin Kenya. The World Health Organization acts as adoor-opener to the public sector. The Foundationsnow support the roll-out to further 20 countries inAfrica, including training and support 42 . Anyonewishing to try the beta software on their own canaccess it at www.episurveyor.org.

Building block 4: contributing to equitableaccess to essential medical products,

vaccines and technologiesMedical products, vaccines and technologies are basicrequirements of high quality health services. Accessto these commodities must be regulated by policies,standards and guidelines which lie in the responsi-bility of the public system. Health systems requiresufficient funds to equip technology hubs such aslaboratories with modern machinery. In-countrymanufacturing sites require specialized staff andcontrolled quality processes. Health staff including

management personnel need skills to use medicalcommodities appropriately; rational use of essentialmedicines is as essential as a sound induction tonew laboratory machines or technical maintenance.

Medical products require comprehensive qualitycontrol to stop the distribution of counterfeit drugsor prevent adverse effects of ineffective or overdoseddrugs. Processes such as procurement, supply, storageand distribution have to be established, monitoredand optimized. Providing access to essential medicalproducts, vaccines and technologies is a challengeto many public health systems in low- and middle-income countries.

On the private sector side, access to moderntechnology and pharmaceuticals is the natural

domain of support from pharmacological and medicaltechnology companies. Corporations operating inthe health sector have an inherent self-interest inefficient service delivery flanked by potent medicaltechnology. Supplementary phi lanthropic ambitionslead to engagements that exceed efforts based onbusiness interests only; they unleash investmentsin capacity development that are not focused onspecific products. Thereby, signif icant added-valuecan be achieved as the following two case studiesdemonstrate.

Doctors and clinic workers use mobile phones to collect and record vital health data and monitor patients status.Photo: UNAIDS/ Joel Selanikio/DataDyne.org

42 Vital Wave Consulting (2009) mHealth or development The opportunity or mobile technology in health care in the developing world, UNFoundation-Voda one Foundation Partnership, Washington and Berkshire.


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Abbott Fund: laboratory support rom nationalto regional level in Tanzania

The Abbott Fund, the philanthropic foundation of the global health care company Abbott, saw that itsproject of strengthening laboratories in Tanzania

developed in steps. Christy Wistar, divisional vicepresident who runs the Abbott Fund office inTanzania, explains: Our original programmes werein support of orphans and vulnerable children. Theneed was critical and we knew we could help make adifference. In 2002, Abbott Chief Executive Officer Miles White visited Tanzania, and it was his experi-ence that led the Abbott Fund to focus its growingsupport on strengthening health systems. White sawfirst hand that Abbott Fund financial support andAbbott volunteers could help address some of the

underlying problems at Muhimbili National Hospital,especially in the areas of infrastructure and staff training. The construction of an outpatient facility totreat 500 patients per day and a clinical laboratory aswell as staff training programmes became the focus of the succeeding project.

The Abbott Funds support in Tanzania is anexample of a project going from the specific to the

general. Wistar explains: The impact of our work atMuhimbili National Hospital convinced us that healthsystem strengthening was an unmet need that Abbottcould help address. Today, we are constructing or modernizing 23 regional-level laboratories to ensurepatients across Tanzania have access to quality labora-tory results.

Modern laboratories are a key to quality healthcare. Without them [laboratories], doctors practiceblindly, says Wistar. We are working in partnershipto deliver 23 laboratories that are standardized to meetnational and international standards. The laboratorystandard design was developed with the Governmentof Tanzania, the US Centers for Disease Control, theAssociation of Public Health Laboratories and inter-national laboratory design experts. The Abbott Fund

is providing safety cabinets and fume hoods, to ensurethe safety of laboratory personnel.

The Government of Tanzania has procured automatedequipment from various diagnostic companies to meettheir clinical needs. In Wistars perspective providingthe laboratory equipment is only the first step: Thegreater challenge is keeping the laboratory opera-tional day-to-day due to challenges such as too few

Abbott Fund Training Programme.Photo: UNAIDS/ Abbott Fund


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trained laboratory personnel, lack of reagents, and fewmaintenance personnel when an equipment problemis encountered. Thats why the Abbott Fund helps tomonitor laboratory performance to make sure that theautomation is operational and reagents are available.

According to the Government of Tanzania, thereare not enough trained laboratory technicians inthe country; even at the regional level hospitals,many professionals are not sufficiently conversantin using modern technology and require further managerial skills of demand definition, forecastingand procurement. To help address the labora-tory personnel shortage, the Abbott Fund provides100 Medical Technologist Scholarships each year sothat Tanzanians can enrol in a three-year laboratorytechnology programme. In addition to scholarships, as

part of its training and implementation programme,Abbott laboratory professionals act as mentors to thenewly modernized regional-level laboratories duringthe first two months of operation.

Maintenance of equipment is another challengingissue in a country the size of Tanzania. All donatedAbbott laboratory equipment is maintained by field-service engineers supported by the Abbott Fund.To help with maintenance of other companiesequipment, the Abbott Fund has been trying to gaintraction on a Crash Cart programme. The concept

is that each laboratory would have a locked cart of parts, tools, and instructions to be used by on-sitepersonnel in case of a broken instrument, minimizingdowntime and travel expense related to instrument

service. So far, cooperation of manufacturers hasbeen very limited due to a reluctance to give outequipment information.

Apart from regional laboratories, the Abbott Fundprogramme also upgrades local health facilities. At

90 sites throughout the country testing and counsel-ling rooms have been built, outpatient clinics havebeen created, laboratories were renovated, staff trainedand equipment and test kits provided. Thus, voluntarycounselling and testing services run by local hospitalHIV management teams have been strengthened tosupplement the care and treatment programmes whichare rolled out in every district.

Monthly meetings with the Minister of Healthand Social Welfare or the Chief Medical Officer develop strong relations and programme oversight.

At Muhimbili National Hospital, the partnership issteered by a committee consisting of officials from thehospital and the Abbott Fund. In addition, the AbbottFund participates in the Donor Partners Group onAIDS to harmonize approaches and avoid duplication.Wistar also regards it as important to employ localcompanies for infrastructure development to providelocal investment and build local capacity.

According to Wistar, many challenges remain inupgrading local health care systems, and while itis necessary to help meet unmet needs, it is also

important to prioritize: We find ourselves drillingwells, installing transformers, developing procurementtools, and much more. Unfortunately, sometimes wehave to say no or sometimes not now when we

reach the limits of our supportpotential.

The Abbott Fund appreciatesthe cooperative and trustfulworking relations with theTanzanian government.According to Wistar, the

secret for this positive relationcan be found in the historyof meeting commitments anddelivering on promises. Our relationship with the govern-ment is built on mutual trustthat has grown over the yearswe have been in Tanzania andcontinues to flourish.

Tanzania clinical laboratory supported by the Abbott Fund.Photo: UNAIDS/Abbott Fund


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Becton, Dickinson and Company: knowledgetrans er and supply solutions in Uganda

Becton, Dickinson and Company is also a US -basedmedical technology company with a strong engage-ment in global health. The rationale for Becton

Dickinsons global health initiative is no differentthan the companys purpose of helping all people livehealthy lives, says Kr ista Thompson, Vice Presidentand General Manager for Global Health in Becton,Dickinson and Comapny: We cannot grow our business unless markets develop. For functioninghealth markets we need a health systems strength-ening strategy.

The Partnership on country-specific laboratorystrengthening that the Company, PEPFAR and theCenter for Disease Control collaborate on, responds

to this demand. As part of national plans developed bythe Ministries of Health of the partnering countries,the laboratory strengthening support shall bring aboutbetter diagnostics for AIDS and TB, continuousquality control and national TB reference and trainingsites43. The programme has started in Uganda, SouthAfrica, and Mozambique, with plans to work in addi-tional African countries.

The foundation of a functioning partnership betweeenBecton, Dickinson and Company, national govern-ments and other stakeholders is a work plan withdefined roles and responsibilities. According to theCompany Global Health Manager the first negotia-tions on laboratory strengthening partnerships havetaken a long time because it required mutual trust tosign a partnership agreement. She adds: Now withexisting examples and experiences, these processes canbe accelerated in new partner countries.

The Company contributes expertise, financialresources and short-term technical assistance throughthe deployment of employee volunteers to the part-nerships. The latter sometimes creates potential for tensions between the private and public partners. For example, the Company proposed to second short-term consultants for three-week intervals to theUgandan National TB Laboratory. The Director of the Laboratory Dr. Moses Joloba recalls his reaction:Initial ly we were sceptical how someone could behelpful who was only there for such a short time.

Jointly, the company and Dr. Joloba defined clear tasks that could be done in a three-week-period suchas training of staff, the mapping of TB treatment sites

or the setting up of a data-base for TB specimen. Thistask def inition worked very well. Dr. Joloba sees thebenefit of an outsider coming with strong energy anda clear three-week objective: A system sometimesneeds an outside impulse to get things done in aspecific period of time.

Governments are often critical of short-term technicalassistance rightly pointing towards the long-termperspective needed for sustainable capacity develop-ment. Training provision is only one side of the coin.Members of staff have to be followed-up by on-the-

job advice and supervision over longer periods of time. The partnership with Becton, Dickinson andCompany has been integrated into the operationalprocesses of the national laboratory. The team of Dr. Joloba monitors the work in the nine TB zones of the country quarterly: If we do not follow up on thetrainings, all that has been learned will be lost.

Becton, Dickinson and Company acknowledges govern-ment reluctance to accept short-term consultancies,but faces its own constraints with respect to long-termsecondment of staff. We are trying to find solutionsto these concerns, stresses Thompson. In Uganda, thepartnership also involves the nongovernmental InfectiousDisease Institute which can now duplicate the trainingswith Becton, Dickinson materials.

The public-private partnership for laboratory

strengthening started in March 2008 in Uganda.Technicians of 95 laboratories have been trained inQuality Management so far and are beginning toimplement an external quality assurance programme.Numerous TB treatment sites have been mappedwith GIS/GPS 44 and a TB Specimen Referralmechanism has been put in place using the UgandaPost Company for the transport of sputum samplesfrom the periphery to Kampala. We first feared thatsamples would be contaminated when transported bya post vehicle. But the contamination rates were not

higher than with an exclusive health transport, saysDr. Joloba.

HIV programmes have been criticized for establishingadditional supply chains 45. But Dr. Joloba as a publichealth officer is optimistic concerning the sustain-ability of the partnership of his institution with thePost Company. We were surprised that the coopera-tion with the Ugandan Post company works so well.He underlines that colleagues from other fields haveshown interest in the transport model.

43 PEPFAR (2007) New public-private partnership to strengthen laboratory systems, PEPFAR, Washington, available at www.pep ar.gov44 Houtz B (20 09) BD/PEPFAR Lab Strengthening Programme, Presentation to the Stop TB Par tners Forum, March 23 25, 2009 in Rio de Janeiro.45 Yu D et al (2008) Investment in HIV/AIDS programmes: Does it help to strengthen health systems in developing countries? In: Globalization and Health,

Vol. 4, No.8.


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Building block 5: contributing tosustainable health fnancing

The financing mechanism of any health system has tofulf il three basic functions:

to generate sufficient funds; to protect the population from financial health

risks; and to purchase or deliver services cost ef fectively.

Universal access to HIV prevention and treatment,care and support also greatly depends on eff icient andequitable health financing. HIV funding contributedto an immense increase of funds from the donor sideas well as from international governments and theprivate sector 46. Innovative fund-raising approaches inthe private sector such as the Product RED Campaigncontribute to numerous AIDS initiatives as well as to theGlobal Fund 47. However, despite this financial influxneeds for health systems strengthening still persist.

Establishing a good financing system to providehealthcare services is a serious challenge to many low-and middle-income countries. About one third of WHO member countries cannot afford a core healthpackage of US$ 40 per person per year. Withoutsufficient funds health systems cannot run their

services, pay health workers and buy commodities.Without pooling of funds and risks, citizens have tomake out-of-pocket payments for medical serviceswhen they become sick potential ly leading to their impoverishment. Without efficient use of funds,services may not respond to needs, funds may getlost in non-transparent administrative processes or synergies between private and public health serviceproviders may not be used 48 .

Ideally, no one should be denied access to neededservices because of poverty and inability to pay.Prepayment, risk pooling, subsidy of the poor andstrategic purchasing of service delivery are mecha-nisms for fair and responsive health financing 49.Insurance schemes are required to ease the pressureon the individual, but also to sustain and co-financeservices provided by the private sector. Public-privatepartnerships addressing this need are very rare.

Mars: promotion and support o the NationalHealth Insurance Scheme o Ghana

The public-private partnership of Mars Inc. in Ghanais a very comprehensive public-private partner-ship integrating aspects such as farmer productivityimprovements, education and chi ld labour. Withrespect to HIV and TB, Mars Inc. cooperates with

Photo: UNAIDS/Becton, Dickinson and Company

46 Yu D et al (2008) Investment in HIV/AIDS programmes: Does it help to strengthen health systems in developing countries? In: Globalization and Health,

Vol. 4, No.8.47 Product Red partners channel a percentage o pro ts rom their products to the Global Fund. So ar, more than a 120 million dollars have been raised

making Product Red the largest private sector contributor to the Global Fund.48 WHO (2008) Toolkit or monitoring health systems strengthening: health systems nancing, WHO, Geneva.49 WHO (2000) Who pays or health, WHO, Geneva.


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various stakeholders of Ghanas health system andthe German Technical Cooperation (GTZ). ThePartnership is based on collaboration agreementswith the National AIDS and Tuberculosis ControlProgrammes, with the Ghana Health Services andselected district health facilities. It has started towork with approximately 12 000 cacao farmers in19 communities in two districts in January 2009.

Apart from education and prevention, thePartenership targets to increase the enrolment of HIVand TB infected farmers in the national care andtreatment programme and to raise the membership of farmers in the national health insurance scheme.

The support of the national health insurance schemewill build on the companys communication andbusiness channels to the cacao farmers. In addition,special Partnership activities to achieve a greater uptake of HIV and TB treatment in rural commu-nities will also provide a platform for insurancepromotion. By using mobile units, for example, thepublic-private partnership will encourage uptake of HIV testing and counselling as well as general healthcheck-ups. Explaining the advantages of the nationalhealth insurance will be part of the campaigning.

The insurance managers of the district health officecooperate closely with the Partnership to educate thefarmers on the scheme and to promote the under-lying idea of solidarity and pooled risk. The DistrictHealth Insurance Officers identify communities withlow enrolment rates and high education needs. Incooperation with the community leaders they alsoidentify which community members require premiumwaivers. As an incentive to join the national healthinsurance scheme at district level, the Partnership willcover the insurance registration costs of the individualfarmer.

The PPP subsidies are intended to lower the barsto insurance enrollment, says Holger Till who isleading the Regional Coordination Unit for HIV &TB of GTZ. Convincing farmers of the benefit of treatment will be easy compared to convincing themto pay for health insurance when they are not sick.The Partnership time frame of three years is short for such an endeavor. But Ernest Asante, Public RelationsOfficer for the District Health Insurance Scheme of Assin North District sees this in a positive light: Thegovernment of Ghana targets to achieve a significantenrolment into the national health insurance schemewithin the next five to ten years. A project time

Ghana armers.Photo: UNAIDS/P.Virot


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frame of three years covers a good part of this. Heexpects the Partnership to make a visible contribu-tion to the enrolment percentage in the communitiesaddressed.

The insurance scheme will only satisfy its members

if the health care services convince with

Documents

HIV-Related Public-Private Partnerships and Health Systems Strengthening