UvA-DARE (Digital Academic Repository) Engaging the private sector in public health challenges in Namibia de Beer, I.H. Publication date 2017 Document Version Final published version License Other Link to publication Citation for published version (APA): de Beer, I. H. (2017). Engaging the private sector in public health challenges in Namibia. General rights It is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), other than for strictly personal, individual use, unless the work is under an open content license (like Creative Commons). Disclaimer/Complaints regulations If you believe that digital publication of certain material infringes any of your rights or (privacy) interests, please let the Library know, stating your reasons. In case of a legitimate complaint, the Library will make the material inaccessible and/or remove it from the website. Please Ask the Library: https://uba.uva.nl/en/contact, or a letter to: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam, The Netherlands. You will be contacted as soon as possible. UvA-DARE is a service provided by the library of the University of Amsterdam (https://dare.uva.nl) Download date:06 Oct 2021 Engaging the Private Sector in Public Health Challenges in Namibia ENGAGING THE PRIVATE SECTOR IN PUBLIC HEALTH | Ingrid de Beer CHALLENGES IN NAMIBIA INGRID DE BEER ENGAGING THE PRIVATE SECTOR IN PUBLIC HEALTH CHALLENGES IN NAMIBIA INGRID DE BEER The studies included in this thesis were a result of operational and original research conducted on PharmAccess Foundation Namibia programs over a period of 12 years. The studies were financially supported by USAID, the Postcode Loterij, through STOP AIDS NOW and the AIDSFONDS and the Ministry of Foreign Affairs Netherlands. PharmAccess Foundation is a Netherlands based organization, with offices in Nigeria, Ghana, Kenya, Tanzania and until 2016 in Namibia. The organization is dedicated to improving access to healthcare in Africa with innovative financing mechanisms. PharmAccess mobilizes public and private resources for the benefit of doctors and patients through health insurance, loans to doctors, clinical standards and quality improvements, private investment and operational research (www.pharmaccess.org). 2 ENGAGING THE PRIVATE SECTOR IN PUBLIC HEALTH CHALLENGES IN NAMIBIA ACADEMISCH PROEFSCHRIFT ter verkrijging van de graad van doctor aan de Universiteit van Amsterdam op gezag van de Rector Magnificus prof.dr.ir.K.I.J Maex ten overstaan van een door het College voor Promoties ingestelde commissie, in het openbaar te verdedigen in de Agnietenkapel op dinsdag 19 december 2017, te 12.00 uur door Ingrid Helene de Beer geboren te Bruck an der Mur, Oostenrijk 3 Promotiecommissie: Promotor: prof. dr. T.F. Rinke de Wit AMC - UvA Copromotor: prof. dr. J. van der Gaag AMC - UvA Overige leden: prof. dr. F.G.J. Cobelens AMC - UvA prof. dr. A.P. Hardon Universiteit van Amsterdam prof. dr. M.P. Prahdan Universiteit van Amsterdam dr. F.G. Feeley Boston University School of Public Health prof. dr. S.R. Moyo Namibia University of Science and Technology Faculteit der Geneeskunde 4 LIST OF ACRONYMS 7 CHAPTER 1 INTRODUCTION 1 9 1.1 Background to the PharmAccess approach to improving healthcare 9 1.1.1 The healthcare landscape in Namibia, 2004 11 1.1.2 The PharmAccess interventions in Namibia 2004-2016 13 1.2 Engagement of the private sector 14 1.3 Strategies to stimulate demand by improving health awareness of patient/client 14 1.4 Strategies to stimulate supply by developing innovative new healthcare service provision 16 1.5 Strategy to innovate new payer mechanisms using temporary subsidization 16 1.6 Strategies to collect and present evidence to support policy-making 17 1.7 Hypotheses 17 References 18 CHAPTER 2 DIAGNOSTIC ACCURACY OF 2 ORAL FLUID-BASED TESTS FOR HIV 21 SURVEILLANCE IN NAMIBIA CHAPTER 3 ANONYMOUS HIV WORKPLACE SURVEYS AS AN ADVOCACY TOOL FOR 25 AFFORDABLE PRIVATE HEALTH INSURANCE IN NAMIBIA CHAPTER 4 UNIVERSITY STUDENTS AND HIV IN NAMIBIA: AN HIV PREVALENCE SURVEY 33 AND A KNOWLEDGE AND ATTITUDE SURVEY CHAPTER 5 HEALTH CARE OPTIONS FOR COMMERCIAL FARM WORKERS IN NAMIBIA 43 CHAPTER 6 ASSESSING THE COSTS OF MOBILE VOLUNTARY COUNSELING AND TESTING 57 AT THE WORK PLACE VERSUS FACILITY BASED VOLUNTARY COUNSELING AND TESTING IN NAMIBIA CHAPTER 7 MOBILE PRIMARY HEALTHCARE SERVICES AND HEALTH OUTCOMES OF 69 CHILDREN IN RURAL NAMIBIA CHAPTER 8 INNOVATION IN NAMIBIA: PRESERVING PRIVATE HEALTH INSURANCE AND 83 HIV/AIDS TREATMENT 5 CHAPTER 9A INCIDENCE OF HIV IN WINDHOEK, NAMIBIA: DEMOGRAPHIC AND 93 SOCIO-ECONOMIC ASSOCIATIONS CHAPTER 9B A CAUTIOUS NOTE ON HOUSEHOLD SURVEYS IN POOR SETTINGS 103 CHAPTER 10 PREVALENCE AND KNOWLEDGE ASSESSMENT OF HIV AND 105 NON-COMMUNICABLE DISEASE RISK FACTORS AMONG FORMAL SECTOR EMPLOYEES IN NAMIBIA CHAPTER 11 DIABETES, HIV AND OTHER HEALTH DETERMINANTS ASSOCIATED WITH 119 ABSENTEEISM AMONG FORMAL SECTOR WORKERS IN NAMIBIA CHAPTER 12 DISCUSSION & RECOMMENDATIONS 133 Strategy 1: To stimulate demand by improving health awareness of the patient/client 138 Strategy 2: To stimulate supply by developing innovative new healthcare service provision 141 Strategy 3: To innovate new payer mechanisms using temporary subsidization 143 Strategy 4: To collect and present evidence to support policy-making 145 Reflection and general recommendations 146 Conclusion 151 References 152 ADDENDUM 157 Summary (in English) 157 Samenvatting (Dutch summary) 161 List of Publications 166 PhD Portfolio 167 Acknowledgements 171 About the author 172 6 LIST OF ACRONYMS AIDS Acquired Immuno-Deficiency Syndrome ART Anti-Retroviral Therapy CoW City of Windhoek CBO Community-based Organization CSO Civil Society Organization FBO Faith Based Organization GFATM Global Fund for HIV/Aids, TB and Malaria HBC Healthworks Business Coalition HIF Health Insurance Fund HIV Human Immunodeficiency Virus HIVREF Health Is Vital Risk Equalization Fund KYE Know Your Epidemic KYR Know Your Response MoHSS Ministry of Health and Social Services NABCOA Namibia Business Coalition on AIDS NAMAF Namibia Medical Aids Federation NCD Non-Communicable Diseases NGO Non-Governmental Organization NIMART Nurse Initiated Management of Anti-Retroviral Therapy NIP Namibia Institute of Pathology NMBF Namibia Medical Benefit Fund OOP Out of Pocket OVC Orphans and Vulnerable Children PEPFAR The United States President’s Emergency Plan for AIDS Relief PPP Public Private Partnership PSEMAS Public Service Medical Aids Scheme REF Risk Equalization Fund SSC Social Security Commission TB Tuberculosis THE Total health expenditure UHCAN Universal Health Coverage Advisory Committee UNDP United Nations Development Program WHO World Health Organization 7 8 1 INTRODUCTION ENGAGING THE PRIVATE SECTOR IN PUBLIC HEALTH CHALLENGES IN NAMIBIA 1.1 Background to the PharmAccess approach to improving healthcare Engaging the private sector in healthcare is a central theme in the work of PharmAccess Foundation, a Dutch not-for-profit organization, based in Amsterdam, with offices in several African countries, including Namibia. A number of studies have shown how private sector can be engaged and leveraged for healthcare in low- and middle income countries e.g. (Rosenberg, Hartwig, & Merson, 2008) (Igumbor, et al., 2014) (Mc Pake & Hanson, 2016) (Whyle, 2016). This thesis will describe interventions developed and applied in Namibia to engage its private sector as an agent to develop and leverage private resources for public health. Interventions and subsequent evaluations are presented according to the PharmAccess model of transi- tioning the vicious circle of poor healthcare in Africa into a virtuous cycle of sustainable healthcare stimu- lating both demand and supply (Schellekens, et al., 2007). The PharmAccess model to change the healthcare environment from the vicious circle of mediocre quality and poorly accessible healthcare into a virtuous cycle of inclusive good quality healthcare recognizes the key stakeholders of healthcare systems as: the patient, the provider and the payer, all three of them functioning in a policy environment that sets the rules of inter- action and exchange. The vicious circle of poor demand and supply of healthcare, which is so common in many sub-Saharan countries (Kirigia & Barry, 2008), is, according to the PharmAccess theory of change (www.pharmaccess. org) caused by a combination of underutilizing the private healthcare sector, low quality of care due to lack of standards, insufficient investments especially in providers at the base of the pyramid and high out of pocket costs for patients due to low levels of pre-payment and risk pooling. This reflects on a healthcare system where trust between stakeholders is essentially lacking: patients/clients not trusting the quality and availability of healthcare services, healthcare providers not trusting patients/clients and payer/insurers to pay, payers/insurers not trusting providers to provide quality care, policy makers not being able to implement policy or regulations resulting in a lack of trust from providers, payers and patients (Schellekens, et al., 2007). The unavailability of prepayment and risk pooling mechanisms for patients results in high out of pocket expenses when confronted with catastrophic health events, with severe economic consequences (Preker A., 9 Lindner, Chernichovsky, & Schellekens, 2103). This situation is aggravated on the supply side by low quality health care due to lack of investment,