Antenatal Care in Low- and Middle-income Countries (LMIC) Delivered through a Public-private Partnership (PPP)

HPS157

Antenatal Care in Low- and Middle-income Countries (LMIC) Delivered through a Public-private Partnership (PPP)

Scientific Posters

Presented on December 2, 2014
Presented as part of HPS-TUB: Health Services Tuesday Poster Discussions

Meera Gopalakrishnan PhD, Abstract Co-Author: Director, Koninklijke Philips NV

Kristen K. DeStigter MD, Presenter: Research Grant, Koninklijke Philips NV Consultant, Koninklijke Philips NV Medical Advisory Board, McKesson Corporation

Eric Z. Silfen MD, Abstract Co-Author: Officer, Koninklijke Philips NV

Over 80% of maternal and neonatal mortality occurs in areas of high birthrate with limited access to healthcare, such as sub-Saharan Africa [WHO 2010]. Infant and maternal mortality continue to be a major health concern in Uganda. It is estimated that ~6,000 Ugandan women die each year due to pregnancy-related complications and for each 1 who dies, 6 survive with chronic and debilitating health conditions such as fistula. Ultrasound examination is well-recognized as an instrument for early detection of life-threatening complications, allowing for timely referral for appropriate life-saving obstetrical care. Improving access to ultrasound technology has the potential to significantly reduce maternal and neonatal deaths and help countries achieve Millennium Development Goals (MDG) 4 and 5 targets. However, access to affordable ultrasound technology at point-of-care coupled with high-quality care delivery is challenging in highly resource-constrained environments. Addressing the complexity and magnitude of these challenges requires domain knowledge, infrastructure capacity and skill-sets housed in both the public and private sectors. Recognizing this need for public-private sector collaboration, we established an NGO-Commercial-Ugandan government public-private partnership (PPP), social business model that emphasized a combination of grass-roots, point-of-care medicine, low-risk government engagement, and a variety of financial models. As a result, we are evaluating a combination of point-of-care ultrasound technology; an inventive care delivery model; and, strong community engagement for improving the clinical outcomes of antenatal medical care in the LMIC setting.

The clinical program was established at ten, church-affiliated, private rural health clinics. Forty-five midwives were trained to perform ultrasound scans and 15,000 scans were performed over the course of three years. Unexpected or urgent clinical findings were identified in 23% of patients, resulting in successful change in clinical management. High-risk conditions diagnosed late in pregnancy using ultrasound included 18% breech or transverse, 4% multiples (twins/triplets), 2.9% abnormal amniotic fluid volume, 2% low lying placentas, 1% placenta previa. This knowledge led to follow-up ultrasound, better-planned deliveries, and/or referrals for C-sections. Additionally observed were “magnet” effects associated with use of the ultrasound. These included a sustained increase in antenatal care visits (ANCs) and skilled deliveries, first time attendance of husbands at the ANCs, and a commensurate 70% increase in testing and treatment of co-morbidities. Finally, once church-affiliated, private clinics were established, clinic services remained fiscally viable when the current level of government funding was subsidized by an affordable patient co-payment of ~ 5,000 UGX (~$2 US) for the course of the pregnancy. Based upon these clinical and financial results, the Ugandan Ministry of Health has approved, for the first time, a similar co-payment model for patients receiving ANC through this program at public clinics and hospitals, thereby significantly expanding affordable access to antenatal care throughout the country.

Public-private partnerships can create value for all partners (Table 1) by synergizing business objectives with social value creation. For ANCs such a clinical program can drive progress in global health by increasing access to life-saving obstetrical care in LMIC and improving community health outcomes, thereby making progress towards MDG 4 and 5 targets. Furthermore, in addition to creating value through the public-private partnership, the clinical program uncovered and began to address new roadblocks such as the need for tools that facilitate collaboration and communication, ways of working in a resource-constrained country, acceptable funding to scale local clinics and the need for sustainable business models for large scale deployment.

A PPP collaboration agreement was signed to prospectively evaluate pregnant women cared for at level III rural health clinics. The agreement outlined expectations as well as deliverables. Onsite visits were conducted twice a year to gain insights directly from the patients. Working groups comprised of individuals with complementary skill-sets were established. The working groups met weekly to establish and implement program deliverables. The working groups also served as a forum for disseminating lessons learned and best practices as well as agents for the creation of affiliations with local clinical networks. In addition, the PPP framework allowed autonomy for the program team to make necessary programmatic changes based upon local dynamics in the field. Finally, program metrics included both clinical outcomes and cost of care.