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Playing the Long Game: Strengthening the Private Health Sector in Ethiopia

Ethiopia’s sustained investments in the private health sector have enabled private providers to become an increasingly important component of health care. Households report that about 43 percent of the money they spend on health goes to the private sector. And in 2017, the Ethiopian Private Health Facilities Owners' Association found that private facilities accounted for more than a quarter of the nation’s 28,326 health facilities, from health posts to specialty medical centers to hospitals. For more than 15 years, Abt Global has partnered with the U.S Agency for International Development (USAID) in Ethiopia to strengthen the capacity of the sector to help achieve universal health coverage and contribute to Ethiopia’s health goals.

To be sure, Ethiopia’s private health sector faces challenges like those in other low- and middle-income countries:

  • insufficient engagement and resources from government
  • lack of incentives for public-private collaboration
  • high turnover of trained private providers
  • variable quality of private health services
  • frequent commodity stock outs
  • limited access to financing.

To help address these issues, we initially focused our support on organizing and improving the visibility of the private health sector. Early on, we assessed the capabilities and needs of private health facilities and government counterparts, then built rapport between them to foster relationships and shared objectives. Over time, under three successive bilateral projects, our emphasis shifted to expanding the volume, quality, governance, and sustainability of priority services in the private health sector. We provided tailored, phased support in five areas, beginning with tuberculosis (TB), followed by family planning, HIV, malaria, and maternal, neonatal, and child health. 

Most recently, from 2015 to 2020, Abt collaborated with the Ministry of Health (MOH) under USAID’s Private Health Sector Project (PHSP) to build on other Abt-led USAID projects in Ethiopia that helped strengthen health financing and governance, including the still-active USAID Health Financing Improvement Program.

PHSP used a systems approach to enhance the private sector’s role. This meant considering factors such as individual and institutional capacities, governance, and information systems that support activities like commodities distribution, linkages to reference laboratories, clinical training, reporting, and supervision. At the outset, PHSP worked with public and private stakeholders to adapt the World Health Organization’s Public-Private Mix (PPM) model for TB for Ethiopia. PHSP identified private health facilities qualified to provide one or more priority health services, the government gave them medicines free of charge, and the facilities dispensed them to clients at no cost.

An important element of the PPM model and Abt’s support was enhancing government and private health association oversight of the private health sector. We acted as a neutral broker, convening collaborators and supporting them as they defined roles, responsibilities, and conditions to work together to improve private health services’ accessibility and quality. 

Sustainability was another cornerstone of PHSP. We produced a Transition and Sustainability Plan midway through the project that served as a roadmap. The plan included strategies to build trust between the government and private health sector and promote local ownership of private health initiatives. It applied lessons learned from past experiences to develop more impactful activities.

Under PHSP, Abt worked with public and private counterparts to help the private health sector play a greater role in achieving Ethiopia’s health goals. Key accomplishments included:

  • Improved quality and access in the private health sector: PHSP helped 862 private health facilities deliver priority services to more than two million patients; trained and mentored over 3,600 private health staff to improve quality of care; linked more than 300 private diagnostic health facilities to Ethiopia’s national laboratory sample transportation system; and developed quality assurance guidelines to aid supportive supervision
  • Increased public-private engagement: PHSP was a constant advocate for public-private engagement. We helped private health facility associations collaborate with Regional Health Bureaus to improve supervision and clinical training of private health facilities.  In 2014, we helped the MOH adopt a Strategic Framework for Public-Private Partnerships for Health and included private sector engagement as an objective of national strategic plans for TB and malaria. In addition, PHSP successfully advocated to the MOH to include private representatives in technical working groups for TB, malaria, HIV, and other priority health areas and prepared guidelines to support implementation of the PPM.
  • Expanded access to credit: PHSP facilitated 86 private loans valued at $11.4 million with two private banks and USAID’s Development Credit Authority. These loans provided financing to expand provision of private services focused on HIV and TB and helped demonstrate a business case for lending by banks to private health providers.

Expansion of the private health sector and its work with the government have increased accessibility with fewer financial barriers for millions of Ethiopians like Dereje Wedaje. “I used to get the services for malaria diagnosis and treatment from a private clinic by travelling 38 kilometers using a rented motorbike and paying 70 to 100 birr ($1.33-1.90)  for two hours travel plus more than 200 birr ($3.80) for the health care,” said the seasonal farm worker from the Beninshangul Gumuz region. “Now I get the malaria treatment near our home, 10 to 20 minutes walking distance, and we pay no money for the service. And health professionals teach us how to prevent the disease and take the drugs properly.”

The Ethiopian government’s investments in the private sector clearly paid off.

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