# 1822 Enhancing the private health sector’s role through access to subsidized malaria commodities: a game changer in ’s supply chain Gilbert Andrianandrasana1, Adjibabi Cherifatou2, Julie Niemczura de Carvalho1, Julie G. Buekens1, Megan Perry1, Angelique Gbaguidi1, Alexis Tchevoede2 1Medical Care Development International, 2 National Malaria Control Program/MOH Benin

INTRODUCTION RESULTS DISCUSSION In Benin, the practice of medicine in the informal private sector, where . 56% of private sector stakeholders interviewed preferred the public supply chain, while only 18.8% Malaria indicators have improved after several years of efforts by the 65% of all consultations occur and 60% of all malaria cases are diagnosed, preferred direct delivery of malaria commodities without a middleman. MOH and its partners, showing engagement of the private sector can be has been one of the health system’s greatest weaknesses. Thus, the NMCP . 60% of entities were willing to provide public malaria commodities for free, while 13.3% only agreed to feasible and beneficial. In order to make further progress, the capacities sought to conduct a pilot project to identify a mechanism for private do so if they were compensated by the MOH. of the health sector need to be expanded and strengthened at the local clinics to access subsidized malaria commodities, improving their role in . Most respondents favored the set‐up of a formal legal framework to be implemented via an MOU level with the private sector’s full participation. In addition, the private Benin’s health system. between the National Malaria Control Program and accredited entities. sector needs to be supported in the implementation of national health . 104 private sector health facilities had access to subsidized malaria commodities (62 in ‐Calavi‐ policies in order to improve health coverage and ensure quality in the So‐ava, 25 in CBGH, 17 in NBT and 18 in DCO health zones); 199 heath workers (144 women) were provision of services. 1) Providing training and accreditation for quality METHODS trained on procedures, ordering, and management tools. assurance of private sector services, and 2) enabling private sector facilities to access subsidized malaria commodities, are good ways for Selected private facilities in 4 health zones enrolled in the pilot received quarterly supervision visits as part • In 2015, 38 key informants and decision‐makers from the public and the MOH and its partners to provide support. Efforts should continue to of the USAID‐funded ARM3 project. Findings from 1‐4 May 2018 are below: private sectors at 20 private clinics (8 medical clinics, 6 medical register all private sector health facilities and integrate them into the Numerator/Denominator % cabinets, and 6 antenatal care centers in Atlantique/, national approach. Borgou/Alibori and Zou/Collines) in six departments were assessed Private clinics that respected the fixed price for commodities set by the NMCP 28/29 96% through a semi‐structured questionnaire. Private clinics that complied with the national treatment protocol for malaria 23/29 79% • In 2017, a pilot activity introduced subsidized malaria commodities to Private clinics that had stocks of antimalarials and other supplies at the DRZ level 29/42 69% RECOMMENDATIONS Private clinics that sent their monthly case reports regularly 18/29 62% 145 private health facilities and pharmacies in 4 health zones (CBGH, The correct completion of management tools increased from 60 % to 78% in CBGH and from 33% to 72% AS, NBT and DCO). for AS. The availability of malaria commodities increased by 15% for AL 24 and 7% for RDTs in NBT health • Scale‐up public private partnership (PPP) to other health zones. • Enrolled private sector health facility staff were trained on the national zone while increasing by 20% for AL 12 and 42% for RDTs in DCO. We noted a significant improvement in • Share performance and experience of the 4 enrolled health zones guidelines, supervision, the national supply chain management system correctly filing the monthly order report, which rose from 21% to 53% in CBGH and from 10% to 67% in AS. with other health zones. (LMIS), and on disease surveillance reporting before receiving • Integrate the approach into a business model to ensure sustainability. commodities. A breakdown of the results of private clinics’ access to malaria commodities in 4 health zones follows • The NMCP should integrate private sector needs into the national below: commodities quantification. The private sector perceives this as a 100% 96 100 good opportunity that would better allow it to fulfill its role with 88 88 90% 86 83 clients and improve the quality of patient care. 80 79 80% 75 69 71 71 70% 68 66 62 REFERENCES 60% 53 50% PALAFOX, B et al. Understanding private sector antimalarial distribution 40% chains: a cross‐sectional mixed methods study in six malaria‐endemic Percentage 30% countries. April 2014. PlosONE: 9; 4. 20% CIP‐BENIN. April 2017. Pratiques de dispensation en matiere de 10% paludisme simple dans les pharmacies d’Officine de , Abomey‐ 0% Calavi et Porto‐Novo (Benin). % of private clinics % of private clinics with % of private clinics % private clinics respected supplied at DRZs regular and complete complied with national fixed prices set by the CARMONA, A, Callahan, C, Banke, K. December 2014. Benin Private monthly reports sent to HZ malaria guidelines NMCP Health Sector Census. Bethesda, MD: Strengthening Health Outcomes Come‐Bopa‐Grand‐Popo‐Houéyogobé Abomey‐Calavi‐Soava through the Private Sector Project, Abt Associates. ‐Boukoumbe‐ ‐‐Ouaké CUELLAR, C, Carmona, A, Harris, A, Korynksi, P. March 2013. Benin Private Health Sector Assessment. Bethesda, MD: Strengthening Health Outcomes through the Private Sector Project, Abt Associates.

98.5 96.7 98.4 97.1 96.3 97.4 94.6 98.2 96.4 97.4 99.399.4 97.2 100 95.4 95.2 95.2 97.2 94.5 90.4 90.4 92.9 92.2 84.8 89.3 95.4 The chart at right shows trends in 90 88.6 96.23 ACKNOWLEDGEMENTS 90.6 93.6 94.9 90.3 87.6 80 94.8 90.8 76.7 84 the completeness of Routine 76.9 83.5 83.9 87.8 85 73.6 86.5 90.3 70 73.4 68.6 71.9 This poster was made possible through support provided by U.S. Agency Malaria Information System (RMIS) 62.2 77.5 60 48.5 62.4 for International Development (USAID), West Africa Mission, Benin reporting from July 2011 through 50 48.8

Percentage Office, US President’s Malaria Initiative (PMI). The authors’ views June 2018, disaggregated by public 40 34.7 39.6 30 expressed in this publication do not necessarily reflect the views of the and private sectors. The NMCP with 21.2 20 support from the ARM3 project 19.9 United States Agency for International Development, the United States 10 Centers for Disease Control and Prevention, or the United States closed much of the gap through its 0 Apr‐Jun Apr‐Jun Apr‐Jun Apr‐Jun Apr‐Jun Apr‐Jun Apr‐Jun Jul‐Sept Jul‐Sept Jul‐Sept Jul‐Sept Jul‐Sept Jul‐Sept Jul‐Sept Oct‐Dec Oct‐Dec Oct‐Dec Oct‐Dec Oct‐Dec Oct‐Dec Oct‐Dec Jan‐Mar Jan‐Mar Jan‐Mar Jan‐Mar Jan‐Mar Jan‐Mar private sector pilot activity. Jan‐Mar Government. 2011 2012 2013 2014 2015 2016 2017 2018

Source: RMIS data Public Private Fig 1. Ste Euphrasie de Vossa Pharmacy in Cotonou Enhancing the private health sector’s role through access to subsidized malaria commodities: game changer in Benin’s supply chain

Gilbert Andrianandrasana1, Adjibabi Cherifatou2, Julie Niemczura de Carvalho3, Julie G. Buekens3, Megan Perry3, Angelique Gbaguidi1, Alexis Tchevoede2,

1Accelerating the Reduction of Malaria Mortality and Morbidity (ARM3/MCDI) (Benin), 2National Malaria Control Program/MOH Benin, 3Medical Care Development International (MCDI) (United States)

As much as 60% of Benin’s malaria cases are diagnosed in the private health sector, where 70% of all antimalarials are also purchased, yet historically, the private sector has not adhered to national malaria diagnosis and treatment guidelines and has faced challenges with maintaining adequate stock-levels of malaria commodities. To enhance the private sector’s role reducing malaria morbidity and mortality, we conducted a study of market preferences and a pilot activity to introduce subsidized malaria commodities at selected private health facilities in Benin. We administered a semi-structured questionnaire to 38 key informants from the public and private sectors, including 20 private clinics (8 medical clinics, 6 medical cabinets, and 6 antenatal care centers in Atlantique/Littoral, Borgou/Alibori and Zou/Collines). We found that the private health sector was amenable to complying with Ministry of Health (MOH) norms and wanted to integrate their malaria commodity needs into the national quantification: 56% of private sector stakeholders interviewed preferred the public supply chain, while only 18.8% preferred direct delivery without a middleman. Most respondents favored the set-up of a formal legal framework to be implemented via an MOU between the National Malaria Control Program and accredited entities. Sixty percent of entities were willing to provide public malaria commodities for free, while 13.3% only agreed to do so if they were compensated by the MOH.

In 2017, we implemented a pilot activity introducing subsidized malaria commodities in 4 health zones via 145 private health facilities and pharmacies. Private sector staff were trained on the national guidelines, supervision, the national supply chain management system, and disease surveillance reporting before receiving supplies. To date, 102 of the 145 accredited private entities have complied with national guidelines, reporting and respecting the sale price of subsidized malaria commodities. Challenges remain, however supplying subsidized malaria commodities through private facilities and pharmacies has proven to be viable.