Innovation in Namibia: preserving private health insurance and HIV/AIDS treatment

Public-private partnership to rapidly strengthen and scale COVID-19 response in Western Kenya

Introduction

In Africa almost half of healthcare services are delivered through private sector providers. These are often underused in national public health responses. To support and accelerate the public sector's COVID-19 response, we facilitated recruitment of additional private sector capacity by initiating a public-private partnership (PPP) in Kisumu County, Kenya. In this manuscript we demonstrate this PPP's performance.

Methods

COVID-19 diagnostic testing formed the basis for a PPP between Kenyan Medical Research Institute (KEMRI), Department of Health Kisumu County, PharmAccess Foundation, and local faith-based and private healthcare facilities: COVID-Dx. First phase COVID-Dx was implemented from June 01, 2020, to March 31, 2021 in Kisumu County, Kenya. Trained laboratory technologists in participating healthcare facilities collected nasopharyngeal and oropharyngeal samples from patients meeting the Kenyan MoH COVID-19 case definition. Healthcare workers in participating facilities collected patient clinical data using a digitized MoH COVID-19 Case Identification Form. We shared aggregated results from these data via (semi-) live dashboards with all relevant stakeholders through their mobile phones and tablets. Statistical analyses were performed using Stata 16 to inform project processes.

Results

Nine private facilities participated in the project. A patient trajectory was developed from case identification to result reporting, all steps supported by a semi-real time digital dashboard. A total of 4,324 PCR tests for SARS-CoV-2 were added to the public response, identifying 425 positives, accounting for 16% of all COVID-19 tests performed in the County over the given time-period. Geo-mapped and time-tagged information on incident cases was depicted on Google maps through PowerBI-dashboards and fed back to policymakers for informed rapid decision making. Preferential COVID-19 testing was performed on health workers at risk, with 1,009 tests performed (up to 43% of all County health workforce).

Conclusion

We demonstrate feasibility of rapidly increasing the public health sector COVID-19 response through coordinated private sector efforts in an African setting. Our PPP intervention in Kisumu, Kenya was based on a joint testing strategy and demonstrated that semi-real time digitalization of patient trajectories can gain significant efficiencies, linking public and private healthcare efforts, increasing transparency, support better quality health services and informing policy makers to target interventions.

A digital mobile health platform increasing efficiency and transparency towards universal health coverage in low- and middle-income countries

In low-and middle-income countries, achieving universal health coverage remains challenging due to insufficient, temporary and fragmented funding as well as limited accessibility to quality healthcare. Leveraging a mobile health platform can be a powerful tool to address these problems. This paper demonstrates how analysing data collected from a mobile health platform helps optimize healthcare provider networks, monitor patient flows and assess the quality and equitability of access to care. The COVID-19 pandemic reinforces the importance of real-time data on health-seeking behaviour. Between 2018 and 2019, as a Kenyan universal health coverage pilot was being planned, Kisumu County, with support from PharmAccess Foundation, implemented household-level digital registration for healthcare and collected socio-economic and healthcare claims data using the M-TIBA platform. In total, 273,350 Kisumu households enrolled. The claims data showed many patients visit higher-level facilities for ailments, that can be treated at primary care levels, unnecessarily. High-level estimate of the disease burden at participating facilities revealed rampant overprescription of pertinent medicines for highly prevalent malaria and respiratory tract infections, exemplifying clinical management deficiencies. M-TIBA data allowed tracking of individual patient trajectories. Analyses of data are shown at the aggregate level. The paper shows how mobile health platforms can be used to generate valuable insights into access to and quality of care. Funding for healthcare can be united through mobile health platforms, limiting the fragmentation in funding. They can be useful for funders, health managers and policymakers to improve the implementation of universal health coverage programs in low-and middle-income countries.

The Tale of Two Epidemics: HIV/AIDS in Ghana and Namibia

Background:

In 2014, the Joint United Nations Programme on HIV/AIDS (UNAIDS) introduced the 90-90-90 goals to eliminate the AIDS epidemic. Namibia was the first African country to meet these goals.

Objective:

To construct a comparative historical narrative of international and government responses to the HIV/AIDS epidemic in the two countries, to identify enabling and non-enabling factors key to mitigate the HIV/AIDS pandemic.

Methods:

We conducted a desk review of public documents, peer-reviewed articles, and media reports to evaluate actions taken by Namibia and Ghana’s governments, donors, and the public and compared disease prevalence and expenditure from all sources.

Results:

Namibia’s progress is due to several factors: the initial shocking escalation of infection rates, seen by donors as a priority; the generalizability of the epidemic generated, which resulted in overwhelming public support for HIV/AIDS programs; and a strong health system with substantial donor investment, allowing for aggressive and early ramp up of ART. Modest donor support relative to the magnitude of the epidemic, a weak health care system, and widespread household cost-sharing are among the factors that diminished support for universal access to HIV treatment in Ghana.

Conclusion:

Four factors played a key role in Namibia’s success: the nature of the HIV/AIDS epidemic, the government and international community's response to the epidemic, health system characteristics, and financing of HIV/AIDS services. Strengthening the health systems to support HIV/AIDS testing and care services, ensuring sustainable ART funding, empowering women, and investing in an efficient surveillance system to generate local data on HIV prevalence would assist in developing targeted programs and allocate resources to where they are needed most.

Reaching 90-90-90: outcomes of a 15-year multi-country HIV workplace programme in sub-Saharan Africa

BACKGROUND

In 2001, an international beverage company implemented an HIV workplace programme providing free antiretroviral treatment (ART) for employees and dependents in sub-Saharan Africa, at a time when ART, cost assessments of ART programmes and related public funding was hardly available. This study describes the outcomes of this programme with respect to achieving the UNAIDS 90-90-90 targets in five African countries and analyses trends over the past 15 years.

METHODS

Anonymous human resource data were analysed in three cohorts of participants (those enrolling in 2001-2005, 2006-2010 and 2011-2015).

RESULTS

Over 15 years, 42,490 unique individuals in five African countries were tested for HIV in this programme and 746 (1.8%) were found to be HIV-infected. Between 2002 and 2015, the proportion of HIV-positive participants on ART increased from 42% to 94% and the proportion of participants on ART who achieved virological suppression increased from 38% to 87%.

CONCLUSIONS

This study shows that in one of the earliest HIV treatment programmes in Africa long-term success has been achieved, approaching the current UNAIDS 90-90-90 targets, demonstrating that the treatment of HIV in developing countries is possible with superior results at low costs (45 US dollars/employee). Reasons for this success include continuous access to on-site quality care and ART and the assistance of an independent NGO with experience in HIV treatment. This provides an argument to continue private sector involvement in international efforts to combat HIV/AIDS, particularly in light of increased ART targets, under-capacity in the public sector and stagnating international funding.

The discovery and development of antiretroviral agents

Since the discovery of HIV as the causative agent of AIDS in 1983/1984, remarkable progress has been made in finding antiretroviral drugs (ARVs) that are effective against it. A major breakthrough occurred in 1996 when it was found that triple drug therapy (HAART) could durably suppress viral replication to minimal levels. It was then widely felt, however, that HAART was too expensive and complex for low- and middle-income countries, and so, with the exception of a few of these countries, such as Brazil, a massive scale-up did not begin until the WHO launched its '3 by 5' initiative and sizeable funding mechanisms, such as the Global Fund to Fight AIDS, TB and Malaria and the US President's Emergency Plan for AIDS Relief (PEPFAR), came into existence. A pivotal enabler of the scale-up was a steady lowering of drug prices through entry of generic antiretrovirals, competition between generic manufacturers and the making of volume commitments. The WHO Prequalification of Medicines Programme and the Expedited Review Provision of the US Food and Drug Administration have been important for the assurance of quality standards. Antiretroviral drug development by research-based pharmaceutical companies continues, with several important innovative products, such as long-acting agents, in the pipeline.

Where will the money come from? Alternative mechanisms to HIV donor funding

BACKGROUND

Donor funding for HIV programs has flattened out in recent years, which limits the ability of HIV programs worldwide to achieve universal access and sustain current progress. This study examines alternative mechanisms for resource mobilization.

METHODS

Potential non-donor funding sources for national HIV responses in low- and middle-income countries were explored through literature review and Global Fund documentation, including data from 17 countries. We identified the source, financing agent, magnitude of resources, frequency of availability, as well as enabling and risk factors.

RESULTS

Four non-donor funding sources for HIV programs were identified: earmarked levy for HIV from country budgets; risk-pooling schemes such as health insurance; debt conversion, in which the creditor country reduces the debt of the debtor country and allocates at least a part of that reduction to health; and concessionary loans from international development banks, which unlike grants, must be repaid. The first two are recurring sources of funding, while the latter two are usually one-time sources, and, if very large, might negatively affect the debtor country's economy. Insurance schemes in five African countries covered less than 6.1% of the HIV expenditure, while social health insurance in four Latin American countries covered 8-11% of the HIV expenditure; in Colombia and Chile, it covered 69% and 60%, respectively. Most low-income countries will find concessionary loans hard to repay, as their HIV programs cost 0.5-4% of GDP. Even in a middle-income country like India, a US$255 million concessionary loan to be repaid over 25 years provided only 7.8% of a 5-year HIV budget. Earmarked levies provided only 15% of the annual HIV funding needs in Zimbabwe and Kenya. Debt conversion provided the same share in Indonesia, but in Pakistan it was much higher - the equivalent of 45% of the annual cost of the national HIV program.

CONCLUSIONS

Domestic sources of funding are important alternatives to consider and might be able to replace donor HIV funding in specific country contexts, coupled with effective prioritization and efficiency measures. Successful resource mobilization design and implementation require close collaboration with other sectors, particularly with the Ministry of Finance, to make sure that the new financing mechanism is fully synchronized with economic growth and that HIV investments yield returns in the form of higher social benefits.

The private sector role in HIV/AIDS in the context of an expanded global response: expenditure trends in five sub-Saharan African countries

Global financing for the HIV response has reached unprecedented levels in recent years. Over US$10 billion were mobilized in 2007, an effort credited with saving the lives of millions of people living with HIV (PLHIV). A relatively unexamined aspect of the global HIV response is the role of the private sector in financing HIV/AIDS services. As the nature of the response evolves from emergency relief to long-term sustainability, understanding current and potential contributions from the private sector is critical. This paper examines trends in private sector financing, management and resource consumption related to HIV/AIDS in five sub-Saharan African countries, with a particular emphasis on the effects of recently scaled-up donor funding on private sector contributions. We analysed National Health Accounts HIV/AIDS subaccount data for Kenya, Malawi, Rwanda, Tanzania and Zambia between 2002 and 2006. HIV subaccounts provide comparable data on the flow of HIV/AIDS funding from source to use. Findings indicate that private sector contributions decreased in all countries except Tanzania. With regards to managing HIV/AIDS funds, non-governmental organizations are increasingly controlling the largest share of resources relative to other stakeholders, whereas private for-profit entities are managing fewer HIV/AIDS resources since the donor influx. The majority of HIV/AIDS funds were spent in the public sector, although a considerable amount was spent at private facilities, largely fuelled by out-of-pocket (OOP) payments. On the whole, OOP spending by PLHIV decreased over the 4-year period, with the exception of Malawi, demonstrating that PLHIV have increased access to free or subsidized HIV/AIDS services. Our findings suggest that the influx of donor funding has led to decreased private contributions for HIV/AIDS. The reduction in private sector investment and engagement raises concerns about the sustainability of HIV/AIDS programmes over the long term, particularly in light of current global economic crisis and emerging competing priorities.

Incidence of HIV in Windhoek, Namibia: demographic and socio-economic associations

Objective

To estimate HIV incidence and prevalence in Windhoek, Namibia and to analyze socio-economic factors related to HIV infection.

Method

In 2006/7, baseline surveys were performed with 1,753 private households living in the greater Windhoek area; follow-up visits took place in 2008 and 2009. Face-to-face socio-economic questionnaires were administrated by trained interviewers; biomedical markers were collected by nurses; GPS codes of household residences were recorded.

Results

The HIV prevalence in the population (aged>12 years) was 11.8% in 2006/7 and 14.6% in 2009. HIV incidence between 2007 and 2009 was 2.4 per 100 person year (95%CI = 1.9–2.9). HIV incidence and prevalence were higher in female populations. HIV incidence appeared non-associated with any socioeconomic factor, indicating universal risk for the population. For women a positive trend was found between low per-capita consumption and HIV acquisition. A HIV knowledge score was strongly associated with HIV incidence for both men and women. High HIV prevalence and incidence was concentrated in the north-western part of the city, an area with lower HIV knowledge, higher HIV risk perception and lower per-capita consumption.

Discussion

The HIV incidence and prevalence figures do not suggest a declining epidemic in Windhoek. Higher vulnerability of women is recorded, most likely related to economic dependency and increasing transactional sex in Namibia. The lack of relation between HIV incidence and socio-economic factors confirms HIV risks for the overall urban community. Appropriate knowledge is strongly associated to lower HIV incidence and prevalence, underscoring the importance of continuous information and education activities for prevention of infection. Geographical areas were identified that would require prioritized HIV campaigning.

The inequitable impact of health shocks on the uninsured in Namibia

The AIDS pandemic in sub-Saharan Africa puts increasing pressure on the buffer capacity of low- and middle-income households without access to health insurance. This paper examines the relationship between health shocks, insurance status and health-seeking behaviour. It also investigates the possible mitigating effects of insurance on income loss and out-of-pocket health expenditure. The study uses a unique dataset based on a random sample of 1769 households and 7343 individuals living in the Greater Windhoek area in Namibia. The survey includes medical testing for HIV infection which allows for the explicit analysis of HIV-related health shocks. We find that the economic consequences of health shocks can be severe for uninsured households even in a country with a relatively well-developed public health care system such as Namibia. The uninsured resort to a variety of coping strategies to deal with the high medical expenses and reductions in income, such as selling assets, taking up credit or receiving financial support from relatives and friends. As HIV-infected individuals increasingly develop AIDS, this will put substantial pressure on the public health care system as well as social support networks. Evidence suggests that private insurance, currently unaffordable to the poor, protects households from the most severe consequences of health shocks.