SHOPS is funded by the U.S. Agency for International Development. Abt Associates leads the project in collaboration with Banyan Global Jhpiego Marie Stopes International Monitor Group O’Hanlon Health Consulting Findings from the Private Health Sector in West Africa: A Six-country Macro-level Assessment Bettina Brunner Regional Manager, Francophone Africa, SHOPS

West Africa Macro PSAs and mHealth Scan Benin, Burkina Faso, Cameroon, Cape Verde, Gambia, Ghana, Guinea, Guinea Bissau, Cote d’Ivoire, Liberia, Mali, Mauritania, Niger, Nigeria, Senegal, Sierra Leone, Togo Macro-level private health sector assessments in six countries to explore opportunities for USAID’s flagship family planning (AGIR-PF) and HIV and AIDS (PACTE-VIH) projects mHealth landscape of 17 countries to identify regional opportunities for public-private mhealth partnerships

Macro-Level Private Sector Assessment 5 components Public private partnerships (PPP) & CSR Role of the private sector Legal and regulatory review Recommendations for partnerships Key NGOs and FBOs

Timeline Country Visit Event Final report publication Dec. 8-17, 2013 Niger Jan Mar , 2014 Togo Burkina Faso Mar. 1-10, 2014 Mar , 2014 May 2014 Ghana Implementing Partners Meeting May 20-21, 2014 Mauritania Feb Mar. 2, 2014 Jan , 2014 Cameroon Côte d’Ivoire Ghana Dissemination Event Feb. 1-10, 2014

Methodology 1.Plan Draft scope of work Select assessment team Engage stakeholders Finalize scope of work 2.Learn Desk review Prepare field survey instruments Fieldwork Debrief key stakeholders 3.Analyze Analyze data Formulate recommendations Draft report 4.Share Disseminate draft report Validate and prioritize recommendations Finalize the report

Health Stakeholders Interviewed Commercial private sector Nonprofit private sector Public sector Development partners  Health care providers (e.g., doctors, nurses, midwives)  Health care facilities (e.g., hospitals, clinics, pharmacies)  Pharmaceutical distributors  Health insurance companies  Diagnostic services (e.g., laboratories)  Multinational companies (e.g., mining companies)  NGOs engaged in health care delivery  Faith-based organizations  Professional and medical associations  Civil society organizations  Business coalitions  Corporate social responsibility NGOs  Ministries of Health, Finance, Public Works, Investment Promotion Departments,  Professional councils and regulatory boards  Public hospitals  Central medical stores  Government commissions on HIV and AIDS  Government health dialogue platforms  International donors (e.g., foundations, foreign national governments)  Multilateral organizations (e.g., UN, WHO, World Bank)

Key Motors for Change in West Africa Regional program in RH & HIV with KfW Diagnostic survey of private health sector eHealth Strategy underway Six local manufacturers identified for local production of ARVs Assistance to 5 laboratories to provide quality control 1 million new FP users by 2015 “De-medicalize, de-centralize, democratize” Engagement of countries in collaboration with donors Relaunch of FP strategies in all USAID West Africa focus countries except Cameroon

FP and HIV in Six Focus Countries Extremely low contraceptive prevalence rate coupled with high total fertility rate Provision of FP & ART by private for- profit providers varies by country Pharmacies are major source of FP products Strong stigma against PLHIV and MSMs in most countries Service delivery highly concentrated in urban areas Contraceptive security committees not operationalized

Public Private Dialogue Strong public sector dialogue with NGOs and FBOs in FP and HIV service delivery Poor engagement with private for-profit sector Dialogue mechanisms exist but not operationalized Private sector not included in health information systems Wide range of professional bodies but poor interface with MOH Regulatory environment is weak

Corporate Social Responsibility Nascent local concept in West Africa Low presence of multinationals, except in extractive industries, large-scale agriculture Company foundations active in HIV Main CSR actors: Private sector coalitions for HIV, chambers of commerce, CSR associations, patronat

Examples of CSR in West Africa Togo: Brasserie BB finances Espoir Vie’s work with OVC Mauritania: BMCI finances STOPSIDA’s activities with fishermen Burkina & Cameroon: Total Foundation finances activities of NGO for HIV activities with truck drivers Regional: Training and outreach on sexually transmitted diseases Employees Families Community Potential Impact

PPPs and Partnerships Lots of contracting out with NGOs & FBOs, much less with private for-profit sector Health PPP idea nascent in region No health PPP units among 6 focus countries No health PPP guidelines in health No private sector strategies in place (Burkina’s is underway)

Burkina Faso Type de StructureTotal Clinic40 Polyclinic9 Medical Center482 Hospital0 Medical Office17 Dental office5 Nursing Facilities179 Birthing Clinic14 CPSP36 Other3 Total361 CategoryTotal Private for-profit 261 Association37 Faith-based organization54 NGO9 Total361 Private Health Structures, 2012 Donor coordination committee and coordinating meeting on contraceptives meet irregularly APROCLIB is key private sector player WBG has strong public-private dialogue program Source: Burkina Faso Ministry of Health 2013

Cote d’Ivoire Health Facilities by Type, 2010 Private health facilities are 52% of total Of 2,036 private health facilities, 73% were unauthorized (2009) Growing manufacturing sector (7), but only supply 4% of market Over 800 pharmacies Strong professional organizations: ACPCI, SYNAMEPI Strong business coalitions (CECI) COSCI Type of FacilityNumberPercent Public sector health facilities, 2009– Semi-public facilities and institutions Public health sector administrative services, 2009– Authorized private health facilities (2009) Unauthorized private health facilities Private faith- and community-based health facilities Total Type of FacilityCTPMTCTARTLab with CD4 Public NGO Community- based Private for-profit4242 Faith-based Workplace Total Number of Sites Providing HIV and AIDS Services by Sector (2010) Source: Barnes et al, 2013 Government of Cote d’Ivoire, 2013

Cameroon Public health facilities (District hospitals, CMAs & Health centers) Faith-Based health facilities (Hospitals & health centers) Private For Profit health facilities (Hospitals, clinics & health centers) 2,566,6531,755,109681,948 5,003,710 Of 4,351 health facilities identified in 2011, 44% in private sector 34% of health personnel active in private sector PPP exists with Confederation of Private Enterprises for distribution of ARVs Coca Cola Africa Foundation provides medical supplies to Ad Luchem Foundation clinics including malaria & HIV medicines work over $15 million AFD has invested 22.8 Euros to standardize and streamline the contracting out process with the MOH. SourceAmount (CFA)Percent Public funds6,837,745, Private funds4,215,189, International/donor funds 19,435,236, Total30,488,171, Cameroon Hospital Attendance, 2012 Funding for HIV by Source, 2012

Mauritania Private for profit facilities in Nouakchott & Nouadhibou include: 15 medical & surgical facilities 47 medical consulting offices 15 primary health stations 118 pharmacies 280 shops selling pharma products Private sector Engagement No public private forum (FP Multi- sectoral working group doesn’t include private for profit sector) Private for-profit poorly represented in MCH and HIV, but private nonprofit well integrated with public sector CPR, Any modern method, by location

Niger Number of private pharmacies in Niamey 85 Number of private pharmacies outside of Niamey 17 Total number of private pharmacies in Niger 102 Number of private physicians, pharmacists, and dental surgeons registered with the local regulatory body 750 Estimated total number of private health providers in Niger Estimated number of wholesalers22 Niger Private Health Sector Private entityPublic entity Description AREVA (commercial corporation) MOH/CILSCILS provides support to AREVA to procure ARVs and reactives for HIV testing. AREVA provides all health services to Arlit population for free. In Niamey, AREVA subsidizes materials for several laboratories. Private providers MOHDoctors at private clinics are contracted by the government to test patients, after which they are referred to CTAs. SIM (FBO)MOHSIM operates 2 hospitals in Maradi (Danja) and Zinder (Galmi). Private pharmacies MOHThrough funding from the Global Fund, the MOH heavily subsidizes malaria test kits in public and private pharmacies across the country. Major commercial businesses MOHAnecdotally, major private companies in Niger have workplace health programs that have PPPs with the MOH. Health PPPs in Niger

Togo 51% health-related spending is out of pocket (2010 CARMMA) For profit private sector is 33% of total Platforms exist but not functioning well: Comité de Coordination du Secteur de la Santé (CCSS), Groupe Inter Bailleur Santé Total number of private pharmacies in Togo 180 Number of private pharmacies in Lomé 162 Number of private pharmacies outside of Lomé 18 Number of private physicians registered with the local regulatory body (in 2013) 200 Estimated total number of private health providers in Togo 2000** Togo Private Health Sector Overview

SHOPS is funded by the U.S. Agency for International Development. Abt Associates leads the project in collaboration with Banyan Global Jhpiego Marie Stopes International Monitor Group O’Hanlon Health Consulting Thank you Bettina Brunner