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Background: Private health care facilities working in partnership with the public health sector is one option to create sustainable health systems and ensure health and well-being for all in low-income countries. As the second-most populous country in Africa with a rapidly growing economy, demand for health services in Ethiopia is increasing and one-quarter of its health facilities are privately owned. The Private Health Sector Program (PHSP), funded by the United States Agency for International Development, implemented a series of public–private partnership in health projects from 2004 to 2020 to address several public health priorities, including tuberculosis, malaria, HIV/AIDS, and family planning. We assessed PHSP’s performance in leadership and governance, access to medicines, health management information systems, human resources, service provision, and finance. Methods: The World Health Organization’s health systems strengthening framework, which is organized around six health system building blocks, guided the assessment. We conducted 50 key informant interviews and a health facility assessment at 106 private health facilities supported by the PHSP to evaluate its performance. Results: All six building blocks were addressed by the program and key informants shared that several policy and strategic changes were conducive to supporting the functioning of private health facilities. The provision of free medicines from the public pharmaceutical logistics system, relaxation of strict regulatory policies that restricted service provision through the private sector, training of private providers, and public–private mix guidelines developed for tuberculosis, malaria, and reproductive, maternal, newborn, child, and adolescent health helped increase the use of services at health facilities. Conclusions: Some challenges and threats to sustainability remain, including fragile partnerships between public and private bodies, resource constraints, mistrust between the public and private sectors, limited incentives for the private sector, and oversight of the quality of services. To continue with gains in the policy environment, service accessibility, and other aspects of the health system, the government and international communities must work collaboratively to address public–private partnerships in health areas that can be strengthened. Future efforts should emphasize a mechanism to ensure that the private sector is capable, incentivized, and supervised to deliver continuous, high-quality and equitable services.
The evaluation design was a retrospective, mixed-method, cross-sectional assessment conducted at program endline without a comparison group. Data sources included qualitative interviews with key informants and a health facility assessment of selected PHFs. We purposively selected stakeholders at national, regional, and facility levels as key informants who were familiar with the PHSP’s activities and were involved in the program and PPM processes. National-level interviews included MOH representatives from directorates involved in priority areas of PHSP support (TB, malaria, MNCH and FP); government and regulatory bodies, such as the Ethiopian Food and Drug Administration (EFDA) and Ethiopian Pharmaceutical Supply Agency (EPSA); and professional associations, such as the Ethiopian Medical Laboratory Association (EMLA). Additional key informants were advisors from the PHSP who provided technical support and guidance to the MOH and RHBs in the implementation of PPMs. At the regional level, we interviewed representatives from RHBs in Tigray, Amhara, Oromia, Addis Ababa, Afar, and Harari; PHF owners; and representatives of regional PHF associations (PHFA). Health facility owners covering different service sectors (TB, malaria, MNCH and FP) were interviewed to understand their perspectives and experiences implementing the PPM. A total of 50 key informant interviews (KIIs) were conducted (Table (Table11). KIIs conducted, by category of informant The health facility assessment (HFA) collected data from 106 of the 332 PHFs supported by the PHSP in 2020. The PHFs were purposefully selected to represent all PHSP regions, types of health facilities, and service delivery technical areas (TB, malaria, and FP) (see Tables Tables22 and and3).3). The sample of facilities covered seven regions and Addis Ababa and was proportional to the total number of PHFs in each service area. PHSP supported a higher number of PHFs from Oromia, Addis Ababa, and Amhara, and these regions yielded a higher percentage of PHFs in the selected sample. Fewer than 10 PHFs from Benishangul-Gumuz, Afar and Gambella received support from PHSP, and we selected 4–5 PHFs from these regions to ensure representation. Sampled health facilities, by region (n = 106) Sampled health facilities, by service delivery technical area (n = 106) *Note: Some PHFs provided services in more than one technical area Some health facilities received PHSP support in more than one technical area and therefore provided more than one type of technical service. For those health facilities, all of the services of interest in this study are included in the sample. Table Table22 presents the percentage distribution of selected PHFs by region, and Addis Ababa. D4I collected data in partnership with the Addis Continental Institute of Public Health (ACIPH) between July and October 2020. Most data were collected over the phone and digitally recorded. The data collection team administered an open-ended, semi-structured interview guide appropriate for different types of stakeholders. The interview guide included questions on the improvements from and contribution of the program, challenges, and gaps; issues of sustainability in the policy environment; service delivery and service utilization; and the overall functioning of the private healthcare system. A team of six interviewers experienced in qualitative research received orientation on the data collection tools, conducted phone interviews in Amharic, took notes, and recorded the interviews with participant consent and permission. The interviewers also conducted some in-person interviews in English, mainly with PHSP staff and government bodies, with proper COVID-19 precautions. If any interviews needed further clarifications, the interviewees were reached through follow-up calls. The qualitative research team translated and transcribed all interviews in English. Transcripts were analyzed using a coding framework based on the program’s purpose, content of the interview guides and the application of broad key themes (achievements, challenges, and gaps). We coded and analyzed the texts by type of respondents and thematic areas to group and identify patterns. The research team discussed iterations of the framework during the coding process as well as evolving themes and data saturation and any interpretations of translations that seemed vague. A pretested, structured questionnaire programmed onto a tablet was used to collect quantitative data for the HFA using Open Data Kit software. A team of six research assistants with medical backgrounds conducted phone interviews and recorded the responses on the tablets. In most cases, the respondents needed to review their records for information on stock-outs and number of trained personnel, and the data collectors called them a second time to retrieve this information. Additionally, the study team requested that HFA respondents take pictures of facility records and send them via telegram, and about half the health facilities did so. The PHFs in the sample responded to questions about the services they provided. We selected key indicators aligned with the thematic areas of support provided to the health systems, including training, supervision, and the availability of medicines. Descriptive analyses were conducted in Stata to assess the status of the health systems-related indicators. This study was carried out in mid-2020, at the height of the first wave of COVID-19 restrictions. Data collection had to be carried out remotely due to the travel constraints and mandatory lockdowns enforced during the pandemic. As a result, KIIs were scheduled and conducted as telephone interviews. A minor proportion (< 10) of interviews were carried out in-person. Likewise the HFA questionnaires were carried out by telephone. Clarifications were confirmed through follow-up calls to participants, as needed. While a typical HFA often includes the observation of services and patient flow and the visual inspection of drug and equipment inventories, this was not possible as a remote study. Given these limitations, we adapted the HFA approach to seek information on key performance indicators and to verify reported data remotely. We also used triangulation across different methods and participants to further strengthen the credibility of the study’s findings. Triangulation allowed the emergence of comparisons and patterns that were important to our analysis. The main instruments consisted of closed-ended and open-ended HFA questionnaires and semi-structured, in-depth interview guides. Respondents included a range of stakeholders from national, regional and health facility levels and included perspectives from policymakers, facility owners, managers and health workers. These different ways of gathering information from different types of respondents allowed a comparison and verification of responses, which increased the validity and dependability of the data. Finally, the evaluation that formed the basis of this study was carried out by an independent, external organization that followed best practices in sampling and remote data collection processes, including providing a clear rationale for the sampling design and sampling frame, determination of qualitative data saturation, and maintaining ethics in the research design. An independent evaluation increases the likelihood of an unbiased performance assessment and enhances the credibility of the findings.
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