Healthline: It’s All About Resources

Tesfaye G. Kidan (PhD) is the chief of party (CoP) for the Private Health Sector Program (PHSP) - a USAID financed intervention that aims to ensure a supportive and sustainable policy environment for the private health sector and enhance both geographic and financial access to essential health service packages through the private sector. The US-educated chief is board certified in internal medicine, infectious diseases, clinical microbiology and epidemiology. Tesfaye got his first degree in Medicine from the American University of Beirut. He did his internship in Ethiopia. He then headed to Seattle, Washington, United States, to specialise in infectious disease research and training. He came back in 2004 to help start the free anti-HIV medication initiative, which was launched in 2005. In this interview with BINYAM ALEMAYEHU, EDITOR-IN-CHIEF, Tesfaye discusses a range of issues related to the private health sector in Ethiopia. Excerpts:

FORTUNE: The Private Health Sector Program (PHSP) in which you are involved aims to optimise, regulate and cement partnership with the public sector for sustainable universal access. But how is it possible for the Program to achieve these, as the two sectors have been mired in misgivings and complaints against one another?

Tesfaye G. Kidan: I would say that the basis for any progress, be it among people or groups, is creating common ground. Thus, there has to be an atmosphere of understanding.

It begins, in this case, with identifying the complaints by the private sector and the demands of the public health sector. These need to be clearly understood. Then, the trial to devise a solution to bring the two together can come.

Always, in the presence of two divergent positions and demands, the best way to move is to have compromise. If you cannot compromise, the two parties remain separate.

What is being done now is to actually go over the health regulations with the parties involved, instead of continuously complaining about it and feeling threatened.

Q: One outstanding issue in the complaints lodged by the private health sector involves standards. Where does the PHSP stand?

It is very clear that we need standards, because they ensure the safety and effectiveness of healthcare delivery. We all agree on that; the public, the private sector and those in between agree that standards are essential.

The issue is how to implement them.

The Ethiopian setting is resource-constrained. We do not have enough human  and material resources. Neither do we have the well-developed skill sets.

If these standards are not contextualised to the Ethiopian situation, they are going to be problematic. But assuming that there is a problem, or you claim that there is a problem, it is not the end of it.

What it means is that it has to be systematically assessed in order to understand the problem, pick up the core issue and solve it. Hence, we do not eliminate the standards. They will be there. But it is a question of how they will be applicable to the Ethiopian situation.

Right now, the government is willing to understand and so is the private sector. There have now been 39 standards released. More are coming.

They are standards that govern the daily practice set up; what the premises should look like; how the professionals should practice and what product you are getting out.

There is an agreement now between the Food, Medicine and Health Care Administration & Control Authority (FMHACA) and the private sector to assess the standards and see where we are.

Q: Health policy has three important pillars – preventive, promotional and curative. But, Ethiopia’s is skewed towards prevention and hence curative care has not progressed as desired. Do you see the balance coming sooner or later?

It is undeniable that you need all the three components that you just mentioned. But the ideal health delivery system is what is known as integrated or comprehensive primary care. That is wellness-oriented.

If a patient comes with only a headache, the doctor, nevertheless, keeps a complete medical history and medical examination. The doctor would then know that the patient actually has diabetes.

If the doctor treats the headache with an aspirin, the diabetes goes untreated. But in the comprehensive care, both are treated. So that is the ideal. There is no reason why Ethiopia’s health system cannot reach that level.

But, as far as curative care is involved, that is why we have levels of care starting from lower clinics all the way through to tertiary hospitals. Ethiopia needs to make sure that curative care is of the highest quality.

It also entails making sure that the professionals involved are competent; the facilities are appropriately staffed and all diagnosis equipment and medications are available.

The private sector has serious resource constraints. It does not have the money to improve facilities and hospitals. They need access to finance. They are willing to take that risk and invest in the centres they manage so that their patients will be the greatest beneficiaries.

The PHSP is currently engaged in convincing the banks to provide loans to the private health sector. We have to convince the banks that the risks, which are exaggerated by the banks, are really not that high.

We do not have lots of facilities being closed. If they are not failing, then why are we considering them as high risk?

Thus, we have to talk to the banks. We have to give them some comfort, so that they could take some risks.

Q: Some experts say that for the curative approach to be effectively realised, a country has to develop. What is your take on this?

Yes, I agree, because again development brings resources. As the country develops, it is going to get more resources. As a country develops and its income level grows, it can afford to pay for some of the resources that it could not previously.

Q: But should this be an excuse for Ethiopia to stick to the preventive approach?

I personally do not think that Ethiopia is actually taking sufficient prevention. In poor countries, we do not pay much attention to the environment. We know that, for instance, taking care of the environment would take care of 70pc of the problems that brings patients to the hospitals.

Even if at lower rates, we are engaged in taking curative medicine that doesn’t take the environment into consideration. In resource-limited countries, 70pc of their problems come from the environment.

Why not take care of the environment instead of building hospitals and buying equipment, then?

Thus, I do not think that the emphasis is deliberately preventive.

Q: But, in a country like Ethiopia where 80pc of the disease burden is infectious, do you think there is actually much room for the profit-oriented private sector?

The PHSP is currently trying to create partnerships between the public and private sectors. The public provides medications for high-impact public health issues like TB, malaria and HIV. Family planning is also included, even though it is not communicable.

The public health sector provides its private counterpart with the medications and commodity so that the private sector would engage in treating these diseases. If the private clinics are trained to acquire the skills and provided with the medications, they do a remarkable job.

All that is needed is to allow them to have access to the medication. The Ethiopian government has now recognised that the treatment of TB should be a public-private mix. Therefore, it has even set aside budget so that the regions could scale this up and expand it to all the private clinics that are appropriately equipped and staffed.

Q: No less than 70pc of health interventions are made through aid. When will the nation be able to own the interventions?

For a long time to come, both public and private healthcare providers will be providing care for Ethiopians. But neither one of these can provide care to the entire population.

What we suggest is that they should partner, as that would create a power of two. Development is a critical issue here. That is how Ethiopia is going to wean itself off the donor dependence and stand on its own two feet.

Q: The health sector is gravely hampered by brain drain. Ethiopia, according to some studies, continues to lead Africa, with Nigeria and Ghana trailing behind. How do you see the issue?

This is a policy issue. How a nation could retain health practitioners is a major issue that is directly related to the salary and working environment.

It all boils down to resources. Ethiopia does not have enough resources to pay at the rate of developed countries; in fact it pays much less.

But more focus needs to be given to incentives other than salary. One is providing land for practitioners to build homes. That goes to supplementing their income. Allowing practitioners to bring items duty free is another. I am not alone in thinking this. Nigeria is doing it now.

Our program, however, is not directly involved in retaining health professionals. Rather, we help marginally, by offering trainings and seminars. But that is a very tiny proportion of what it takes to retain professionals.

Q: Most of the remedies in the health sector got imported from outside. Do you see hope that they will soon come from Ethiopia?

With time, I would say, the importation of experts to build our health system will improve. Expertise and experience are dependent on time. But, perhaps, the expertise in Ethiopia may be sufficient and what is lacking is how to organise and manage the expertise so that there is a complete system.

The health system starts from policy. That being the first tier, it then goes down to resources and finally the service. The system will be complete when the resources are complete. I am referring to the retention of skilled human resource.

My personal observation is that we are not adding experts from abroad. Even if we do that, Ethiopia is actually owning and developing capacity.

Q: Could you cite some examples to illustrate that?

Sure. When we started the ART, there was no expertise at all. We decided to bring in the expertise. But instead of allowing the experts to continue to take care of HIV patients, we wanted them to train local people as trainers.

Hence, coming back to reaffirm my observation, I can say that in the last 10 years, there have been less experts coming from abroad and more of local experts taking over.

The calculation for Ethiopia to be totally independent is hard for me to tell, but it is foreseeable. In the near future Ethiopia will have its own expertise.


Published on March 30, 2014 [ Vol 14 ,No 726]



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