Innovations in access to TB and HIV/AIDS care in sub-Saharan Africa: dynamic engagement of the private sector.

A village of 5000 people in Africa will never justify the building of a new tuberculosis (TB) clinic. In Kenya, such a village will produce 25 new cases of TB each year, not all of whom will seek care. The costs of bricks and mortar, equipment, drugs and support make serving these people virtually impossible within government health care systems. As the World Health Organization (WHO) takes up the challenge of human resource needs for human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), we propose an alternative for these 25 patients, and for the others in the village who are ill with opportunistic infections from HIV or with full-blown AIDS. We know, from demographic and health survey (DHS) data and other sources, that these people are likely to be getting care from a local private provider, if they get care at all. Our proposal is for a system to utilise this existing pool of human resources in health. Working with the private sector to achieve public health goals is both possible and pragmatic. It is possible to improve service quality through using a well designed system for training, support, and both managerial and clinical supervision, suited to African conditions, and incorporating appropriate provider incentives. With the knowledge from franchise experience in services, retail and health systems in both OECD and developing countries, we believe that diagnosis and treatment for TB, HIV and AIDS can be affordably added to the package of care already being offered by many medical providers. For the villager without available quality care, the resident of urban slums not served by the national health programmes, and the many people who choose to be treated in the private sector because of expected better care, faster service and guaranteed anonymity, we propose a system of franchised private providers. This would assure quality and access to those for whom government providers are out of reach or not desired. Our own financial analysis is supported by the evidence from existing health franchises and economic evaluations of pilot private sector TB treatment programmes. This makes us confident that, in many places, these services can be provided for significantly less cost than would be required were government programmes to be expanded and adjusted in order to serve the same populations (McBride and Ahmed 2001; Floyd unpub).