The response to HIV/AIDS in several countries has been impeded by human resources for health shortages — and to make headway in the fight against HIV, many countries have received support from donors to hire thousands of additional health workers for HIV service delivery.
Millions more people are accessing antiretroviral drugs thanks to special agreements that waive the patent for lower-income countries — including most recently for WHO-recommended dolutegravir.
These health workers have become integral to the HIV response, but as external funding declines, few governments are prepared to absorb them. Many of these same countries have an active private health sector that is already a key player in primary health care, family planning, and maternal and child health.
However, the private sector largely has not been explored as an avenue to supplement government capacity for HIV service delivery. In some countries, private for-profit and nonprofit entities are active in HIV clinical services and their health workers are well-positioned to do more to contribute to UNAIDS’ 95-95-95 goals: scaling up HIV testing, initiating people living with HIV on antiretroviral therapy and supporting those receiving ART to achieve viral load suppression.
For example, the Unjani Clinic Network in South Africa is using its existing human resources for health for HIV service delivery and is sustainably growing its health workforce. This private sector franchise is comprised of 65 clinics that shift primary health care tasks from doctors to professional nurses, who are the owners and operators of the individual clinics. Clinics are strategically located in low-income areas, where need is high and demand is sufficient — when nurses apply to become Unjani Clinic owners, they must first conduct a community demand survey.
All clinics provide a standardized list of affordable primary health care services, and a significant number of nurses are trained in nurse-initiated management of ART, allowing them to offer a variety of HIV services. Unjani plans to expand to 350 clinics treating millions of South Africans nationwide. Under South Africa’s upcoming national health insurance policy, Unjani may be able to receive compensation from the government for providing services.
Ryan Morhard, project lead for global health security with the World Economic Forum, talks about the need for greater cooperation between the private and public sectors in global health security.
Glocal Healthcare operates digital dispensaries in India. These dispensaries offer screening tests, but no other HIV services — yet. Glocal is an example of the innovative service delivery models the private sector could leverage to provide HIV care. While each of Glocal’s dispensaries is staffed by a nurse, technology enables the clinics to provide services beyond a nurse’s traditional scope of practice.
The nurse examines patients and inputs the observations into a system managed by artificial intelligence. AI runs clinical algorithms to inform the diagnosis. If necessary, the nurse can use the system to connect with a remote doctor for a teleconsultation, and to perform laboratory tests. Once a diagnosis is made, the patient’s prescription is transmitted to a machine that dispenses the correct medication and dose. The patient is charged a modest flat fee for the entire service and receives a follow-up call from the nurse within a week.
With a small footprint and low overhead, these digital dispensaries can sustainably reach rural and hard-to-reach clientele with essential services.
Framework for action
While the private sector offers significant opportunities for HIV service delivery, leveraging its capacity to achieve the 95-95-95 goals requires support from policymakers, ministries of health, donors, implementing partners, and private providers. Stakeholders should keep the following framework for action in mind as they work toward this end:
1. Recognize a role for the for-profit private sector in HIV service delivery
For-profit private providers will not participate unless they see a market opportunity, such as high demand or low barriers to entry. Public-private contracts, capital financing opportunities, and policies that incentivize entry and increase access to required resources — such as the ARV supply chain — can encourage market entry and expansion.
2. Support regulation that allows the private sector to innovate
The ability to innovate is one of the private sector’s greatest strengths. Policymakers can establish regulations that allow innovative or flexible business practices and assure quality and should be mindful of policies that might inadvertently discourage start-ups and small businesses.
3. Choose financing mechanisms that leverage the private sector to build equity
Models can include the public sector wholly paying for private sector services, clients with the ability and willingness to pay covering the cost of their own care, or a combination of payment mechanisms. The payer arrangements will impact how the private sector employs and utilizes its health workforce.
4. Partner with the private sector to provide differentiated care to clients of all income tiers
Private providers have established sustainable models that are ready to scale and, in some cases, absorb additional health workers to deliver a variety of HIV services. Partnering with the private sector opens last-mile opportunities to better serve existing clients with more tailored services.
With coordinated encouragement and investment from all stakeholders, the private sector’s health workforce can make a significant contribution to sustaining HIV services.