The Journey to Private Sector Engagement in Liberia

– [Ryan] All right, good All right, just wanna make sure everyone Hello Okay, great Good afternoon Good morning and good night, everyone Hello, welcome to the webinar on the journey to private sector engagement in Liberia For those of you that don’t know me, my name is Ryan Ubuntu Olson and I’m a technical advisor with the Health Policy Plus project funded by USAID We apologize for our slight delayed start this morning We’re having a little technical difficulties, but we’re excited for this presentation that we’ve been working really hard on for the past couple weeks and look forward to presenting it to all of you I just wanted to open off with a few quick reminders and terms of this particular webinar Just so you know, this webinar is being recorded and we will eventually post the recording to the HP plus webinar’s page, following this event We would love to hear from you And we welcome your questions at any time Please make sure you submit your questions via the question box in your webinar setup And we’ll probably get to those in our q&a session at the end of this session I wanted to make sure you all know as we’re experiencing right now, a web conferencing platforms like this are getting an unusual amount of traffic and thus we may experience additional technical difficulties So if that does take place, please, we ask for your forgiveness And finally, we ask that if you happen to be unmuted or have your camera on, please mute yourself and turn off that camera We have literally about 100 people are expected to join today We’re so excited for all of you So it’d be awful if we were interrupting each other, so please make sure you’re mindful of that Anyway, that concludes my particular announcements and I’d love to now turn it over to my dear colleague, Anna Gerrard to help kick it off Hello, Anna – [Anna] Hi, thanks, Ryan Hello, everybody Thanks for joining today’s webinar My name is Anna Gerrard, senior technical advisor for private health Palladium, and I’ll be leading today’s webinar on the journey to private sector engagement in Liberia Firstly, let me extend a warm welcome to our panelists today Namely, Dr. Nicole Cooper, clinical director of Jahmale Medical Solutions and chair of the Healthcare Federation of Liberia Dr. Amit Thakker, executive chairman of the African health business and Dr Cuallau Jabbeh Howe, who is the director of subsidies and grants at the Ministry of Health of Liberia, welcome all So our agenda today will be as follows First of all, I’ll take a few minutes to write some context for everyone Health Policy plus conducted a private sector assessment in mid 2019 And I can provide a brief overview of the findings, and this will help set the scene Then I’ll hand over to Amit, who will discuss the role of Healthcare Federation’s across Africa in private sector engagement And following Amit will be Nicole, who will discuss the history of the Federation Its current role in supporting COVID-19 response efforts and the Federation’s overall private sector engagement objectives And lastly, Dr. Jabbeh Howe will provide the perspective of the public sector with regards to private sector engagement And we’ll then have about 10 minutes we hope remaining for questions at the end So, as Ryan said, do place your questions in the box on the right So firstly, as I mentioned, I’d like to provide some context drawing from the frame findings of the Liberia private sector assessment Here namely, I draw your attention to the importance of Monrovia as the capital city Given it has two third the population This high concentration of people in the capital places high importance on the Urban Health System, which is actually where the majority of private facilities are also located The population in Liberia is also very young cause of high birth rate with 70% of the population under 35 and 7% of the population over the age of 55 Economically, the continual decline of the Liberian dollar against the US dollar has a significant impact on the cost of medicines, which are all largely imported, and all imported in US dollars At a time of the research for the assessment, the exchange rate was fluctuating daily, and I’ll put a pin in that for now and come back to this point later There are a couple of key policy documents that include references on gauging the private health sector In response to the Ebola outbreak a number of years ago, the government of Liberia drafted the investment plan, of building a resilient health system

And this document sets out the importance of regulating the quality of care in the private service delivery sector, regular monitoring the private facilities and the need for specialized training in Ebola management But really, there are very limited references overall and other policy documents And this may be due in part to the private health market remaining fairly small up until 2015 And you’ll notice on your bottom right hand side of your screen, the private sector made up only 2% of total health expenditure in 2015 However, this figured up to 8% Health Policy plus was charged with conducting a private sector assessment to determine the current scale and scope of the private service delivery sector in Liberia, examining the enabling environment as well as to identify practical opportunities to strengthen the private health sector And there was a special focus on family planning For this assessment, the private sector was defined as all non governmental entities As part of the primary research, 30 facilities were surveyed, which is about 10% of the total private market A number of actors in the enabling environment was also surveyed Diagnostic labs pharmaceutical companies, importers, distributors and wholesalers and private health insurance companies What’s more, a couple of years ago the government of Liberia undertook a service availability and readiness assessment And this also helped provide in depth information on the private health sector We also looked at the malaria indicator survey, which provided information antenatal care, family planning, labor and delivery I’ll present some of these secondary data before moving on to the findings of the primary research In terms of the size of the private sector, there are 258 functional private facilities 73% is located Montserrado county which is where Monrovia, the capital is located Primary level facilities make up the lion’s share of the private health market at 88% of all facilities There are 16 health centers which is 7% (mumbles) 12 hospitals, which is 5% In terms of family planning in urban areas, as you can see just over half of private facilities offer family planning services, and 27% of clients state that they access family planning services from the private sector In terms of the distribution of equity across facility types, the private sectors on the right hand side of the bar chart you see here, and is generally wealth quintiles three to five, which is broadly defined as middle to upper class that utilize the private sector family planning And now I’ll show a short summary of the primary research findings from the assessment In terms of owning our facility to obtain a health facility license, the facility must have a licensed physician on staff, any facility that is not actually (mumbles) by a physician, not (mumbles) 82% of those surveyed here, as shown in the bar chart, all need to have a physician on staff And this regulation places a barrier on the growth of the private service delivery, given that there are such a small number of total physicians available in the country To start these businesses, everyone uses their own money, borrows funds from friends and family Yet not one person surveyed got a formal loan to start up their business And this is really indicative of a lack of availability of formal financing for the health sector I’ll cover just a few points about service provision here There’s a lot covered in the private sector assessment report, and I’d recommend you have a look there if you’re interested in knowing more There is very little diversification of service offerings among facilities in this area And one informant actually remarked on this in an interview In terms of the availability of family planning services at this point in time in 2019, facilities receiving a free range of commodities from the public sector, which actually also included family planning commodities, they would receive a small stock every so often in exchange for submitting their health data on time The condition was that they offer the services and product 100% free of charge to the client And in a moment, I’ll walk you through how that impacts the facility’s bottom line For commodities in general, overall, the private sector supply chain was working well at that time and few facilities reported regular stock outs There were however, reports that indicated severely constrained cash flow, which was recreating artificial stock outs of commodities Anecdotally, one of the reasons cited was that this was due to the lack of reimbursements for services covered by private health insurance, and I’ll come back to that point in a moment In terms of tradings, there’s very limited support offered to the private sector by way of external trainings,

and in service trainings in house are quite limited It was reported that the Ministry of Health hosts trainings one to two times a year, and some places are offered actually to the private sector But the places are reported to be offered to facility owners at last minute, and it was quite difficult for them to arrange someone to attend to always Now, the availability of some services was also limited in some cases due to the lack of electricity And this was quite a challenge at the time of the assessment Most of those surveyed were operating almost fully off generators and to get a sense of what this costs for a one-story clinic with a small number of consultation rooms The cost to operate a generator’s estimated to be around 20 US dollars a day The last piece of information about health facilities which I’d like to show you today is on pricing In terms of consultation fees, so those fees that are paid upon registering and entering the facility It’s around one US dollar for primary clinics, and 68% of primary facilities fall around this price For secondary clinics, the price hovers around the same point And for hospitals, it’s around five to 10 US dollars And you’ll note, there’s a very small sample of hospitals here, as there just aren’t that many in Liberia So if the private sector is regulated to provide services for free in some cases, as was the case at that point for family planning, this is the minimum gross revenue that they’re going to forego when doing that Now moving on to private health insurance and coming back to that point, there are 18 companies who cover around 3% of the population and they cover formal workers only And as you recall, before, I mentioned that facilities were citing that some private insurance companies were not reimbursing for service rendered for several months and some really not at all This was creating a financial strain on facilities Who were still offering the services to clients because they had a valid insurance card And what was heard at a time is that the premium holders, which were largely governmental organizations, were not paying for their premiums on time And this had a knock on effect, which was being borne by facilities And other parts of the same story was also heard when surveying the pharmaceutical sector And the market here is dominated by three larger pharmaceutical importers, who are also wholesalers and retailers There’s no pharmaceutical manufacture in Liberia, so everything is imported and mostly in US dollars So if you recall back to the earlier point around currency exchange fluctuations, you’ll note that that means that a financial risk is placed on those within the supply chain, if the exchange rate is fluctuating regularly First staff surveyed all really reported there are limited stock outs, as I mentioned before We were told that family planning commodities were generally not imported as the government offers those services for free The only really sold emergency contraception (mumbles) comes with regards to family planning, really on their treatment on the other hand, they do procure and consider the malaria market large enough, both free and paid commodities Vaccines are also occasionally imported for the government And this is on an on demand basis, when there were stock outs, and they only import a limited amount of stock for that particular situation In terms of pricing, they reported adding a fixed markup or standard, they’re fixed prices for clients with discounts offered for paying in cash, for example, credit’s offered pretty much at standard There were some rumblings at the time about the knock on effect of this cash flow issue at the city level And one responded here saying and I quote that, “Customers are taking me as a financier.” And at that time, some public hospitals were also still sourcing drugs from private pharmacies on credit, despite the relative inability to repay that’s on The last point I’ll raise here, which is really related to private sector engagement is aside from the public sector offering free commodities to the private sector, they were also offering annual subsidies and grants to a small number of private entities and how these facilities were selected at that point in time was unclear At the start of the last financial year in September, this area was under review and was assigned to the grants and subsidies unit, which Dr. Jabbeh Howe on the panel today is gonna talk about Lastly, I’d like to quickly highlight a couple of the key recommendations that health policy plus has been moving forward to this year Firstly, one of the major points coming out of the assessment, was the lack of any consolidating body for the private health sector If the public sector wanted to engage the private sector, there was no, next slide, there was no focal point to actually engage, which makes it all the more difficult to start private sector engagement Next slide And in January of this year,

the Healthcare Federation of Liberia was officially launched and Nicole will talk to you more about this in a moment The second point is that health policy plus is currently supporting the Ministry of Health development, the first private sector engagement framework, which will help guide their approach to collaborating with the private health sector And lastly, health policy plus is also addressing the dire lack of access to finance for health businesses, by providing technical assistance to financial institution Monrovia armed in parallel, strengthening financial literacy through targeted trains for health facilities And we’re specifically targeting those wanting to access formal loans And we hope that this will help businesses make those improvements needed to support their expansion efforts For those that want to know more, here’s a link to the assessment which is to be found on the health policy plus website And I look forward to answering your questions at the end of the webinar Now over to Amit who is gonna talk to you more about, the role of Federation’s across Africa and private sector engagements Over to you, Amit – [Amit] Thank you Anna And thank you to HP plus the Palladium group for giving me this opportunity to speak about the role of the private sector engagement and the role of the private healthcare Federation I will move on, on the next slide you will see just like Anna outlined in the private sector assessment report, and some of her recommendation, touched on a few challenges that the continent is facing In a country of 55 countries with 1.2 billion people In the last two decades, we have seen these seven challenges to be cross cutting and affecting almost the entire continent We know that the private sector provision of health care on this continent versus public sector is almost at a 50, 50 level Some countries, we have a deeper private sector service provision than others And the social economic status of those seeking private sector tend to be in the higher quintile But even the ones in the lower quintile do seek services from the private sector Very briefly, leadership and partnerships have been weak, and need to be strengthened The second point is access to capital That Anna also mentioned, it’s been pretty expensive to get capital injected into the healthcare sector The third point is, the regulatory environment has not been enabling, an absence of appropriate regulations have made investors shy away from driving greater funding into the sector The fourth one is the disease burden and also connected to that, is the human resources for health And where we’ve had scanty health personnel dealing with all these high disease burdens that we face Maternal and child mortality is a key aspect that many programs have been looking at innovations on how to manage that Healthcare financing is a big topic and under SDG three in the universal health coverage, we wanna widen the safety net in Africa, because out of pocket expenses remain a huge barrier in accessing these services And finally, healthcare delivery infrastructure, and including technology and equipment, is subject to foreign exchange that also was mentioned earlier, and these global inputs become extremely expensive So in my next slide, I’ll talk a little bit about how we see the private sector federations coming together to find a solution for better healthcare So in the last 14 years, there’s been a movement and almost 30 countries in Africa are adopting, creating a unified voice that Anna spoke about that can continue engaging government in strengthening the health systems in country What we have found, is the private sector federations bring together in three categories, almost everyone from urban and rural setup to be part of a unified voice known as a private healthcare Federation, which you will hear more about from Nicole, on how they manage to do that in Liberia The Ministry of Health then has a single focal point They can discuss regulations, they can discuss appropriate supply chain management and they continuously have policies that will propel the growth

of the private sector, moving it from maybe 8% like in Liberia, and higher contributions to the total health expenditure The federations then connect with also the other business councils so that they remain relevant in the macro economic framework, promoting affordable, quality healthcare services across the whole sector On my next slide, I’ll tell you the importance of the private healthcare Federations and number one is pretty clear I mean, we are much large as a private sector in Africa in health, than we were 30 years ago So it’s about time for the private sector federations to get organized and make a strong impact The second one is the health sector reforms are top of the mind agenda for many Ministries of Health, and leveraging the private sector most effectively in country can improve health indicators The third one, as we have heard earlier, is we need a unified focal point for the Ministries of Health to continuously engage So we are trying to reduce the fragmented non-state health sector through a federation And fourth is when we have a public-private dialogue, we build trust And this trust is brought through an institutionalization partnership, that Federations form In my next slide, I will talk to you about still some of the challenges that the private sector face And those are the six challenges that you see on this particular slide And very quickly, I already talked about the fragmentation The second one is competition There has been a feel of them and us, between public and private, but through the public-private dialogue, trust is building up and you’re seeing as a unified health system that’s helping the country, get much better, deliver growth and deliver better healthcare The third is, of course, the private sector has to look at sustainability And if it doesn’t get any subsidies, it has to focus on where it can receive revenue This is the reason why they’re more focused in the urban areas and not as much as we think they should be in the rural areas It’s a small market And so we need to be innovative on how much we can expand the market So regional economic communities like ECOWAS, EAC and others tend to be very favorable discussions in the private sector Low purchasing power is what’s another challenge because out of pocket expenses, make it very difficult for many of these citizens to seek health care at private facilities and therefore the need for national health insurance And finally, limited infrastructure is continuously a challenge because it’s very costly In the next slide, the progress made in across Africa is great You can see so many countries since the year 2000 have taken on to this idea of forming a federation Some of them are on early stages, some have incubated their federations really well, they have a continuous engagement with the Ministry of Health, they even present reports to at the presidential roundtable, like in Kenya And in since 2012, we’ve been forming a regional Federation like the East Africa healthcare Federation, and we’ve also got the West Africa healthcare Federation In the next slide, I’ll just clarify what private sector actually means When we refer to private sector in Africa, we refer to the non state health actors It’s no longer about profit or not for profit It’s for impact and if you look at this chart, it shows that the private sector organizations are actually active in all the six building blocks of WHO This means that the private sector is playing a full complete role in improving health across the continent So what is the pathway? In my next slide, I’ll talk to you about how does it work in a country It’s very simple It’s just, five step approach We’d go in and find champions in the private sector, investors, hospital owners, people who own pharmacies or insurance companies And then we bring those champions together, we go straight for a registration, using the legal format in country, we try and include members from all aspects in healthcare and bring members also from outside the capital city We design activities for that country That speaks to its current needs, whether it’s Family Planning, sexual reproductive health

or whether it’s a universal health coverage And step five is to develop stronger partnerships So this pathway has worked So what is the advocacy platform in my next slide? For greater coordination in partnership, these five key areas have worked really well and the Ministries of health has appreciated the advocacy and frank dialogue that the Federations bring They’ve also appreciated the governance where we have members and all private sector organizations have a voice, they have a board and they have transparency on how they keep priority engagements with the Ministries of Health They set the stage and they give frank opinions on regulations that are hurting the private sector, and what adjustments could be made to improve health And finally bridging the gap and we help the Ministry of Health, understand how the private sector operate And through this, we also understand how the ministries of health operate, bringing the two entities together with greater trust So let me give you an example of Liberia in my next slide When I talk about inclusivity You will see on the left, when we talk about inclusivity, it’s not Liberia private healthcare facilities federation, but it brings in medical equipment providers, hospitals, insurance and all those into a one unified umbrella body That then reports into the regional Federation, known as the West Africa private healthcare Federation, who then reports at the Africa healthcare Federation, comprised of the five regions This brings, it makes it easier for sharing best practices, changing regional regulations and promoting greater coordination In my next slide, you will see that some of the countries that I mentioned, approximately 30 countries have formed a federation The private sector has divided itself in a regional manner to take advantage of the regional economic communities like ECOWAS, EAC to drive a larger market, to drive down the costs of healthcare but improve its quality We have a connection with Africa Union, as well as World Health Organization And it seems to be moving well In my next slide, which I will use to conclude, let me just show you some accomplishments of the Africa healthcare Federation Through this model, over the last 14 years, we’ve been able to filter down some financial incentives that have brought the footprint of private sector to increase in country We’ve been able to harmonize techs and remove unnecessary costs At regional level, we have advocated for free movement of healthcare personnel, doctors, nurses, pharmacists, between countries example between Rwanda and Uganda, there is no longer a work permit required, which used to be $4,000 for two years Therefore driving down costs We’ve also been able at regional level to harmonize the taxes and pre verification fees of medicines like paracetamol and antibiotics, crossing borders to reduce counterfeit and fake medicines being shuttled from country to country Now, at the Continental level, we have started building great trust with ministries of health AU and others through this organized public-private dialogue And finally, the knowledge sharing platform has been immense, such as this webinar, but we have a long way to go And now I hand it over back to Nicole, who will tell you a little bit about the journey in Liberia Thank you – [Nicole] Hi, everyone My name is Dr. Nicole Cooper As Amit mentioned, I am the clinical director at Jahmale Medical Solutions in Monrovia, Liberia And I’m also the chairperson of the healthcare federation of Liberia I guess you could say that HFL then is the next case study that we’ll be moving into So, next slide I will just go into that now As Amit mentioned, the healthcare Federations are unifying voices for the private health sector and as over the course of 2019 in Liberia,

various institutions in the private health sector held organizational meetings And eventually, with foundational support from USAID through the implementing partner HP plus who has also brought us here today And several local sponsors HFL was able to have an official launch in January of 2020 With our first annual general meeting held shortly thereafter, in February 2020, and the election of a seven member board of directors and the establishment of our internal committees to address each of our following focus areas that you see listed here, which are public sector advocacy, public-private partnerships for health, access to finance for facilities, grouped procurement and supply chain, incentives and accreditation within our facilities We really work together on these focus areas as Amit mentioned earlier, with a goal of creating an enabling environment that will lead to increase access to high quality private health care Next slide So immediately after that first annual general meeting, we presented our credentials here in this picture, to honorable Dr. Wilhemina Jalla, the Minister of health of the Republic of Liberia, and had our first ministerial stakeholder forum Dr. Jalla has been a strong supporter of the HFL during the entire Inception process, and at this first official meeting, we signed a Memorandum of cooperation And the Ministry of Health also designated a private sector liaison that is the Deputy Minister for administration Honorable Noor Howard, as well as Dr. Cuallau Jabbbeh Howe who is on this call today with us Federation ministerial forum, stakeholder forums are a critical part of our work Because they are the regular scheduled meetings that we, the private sector representatives have And then we use them to engage in ministry of health around topics of mutual concern between the private health sector and the health sector in general, as well as potential areas of collaboration Next slide So from that point on February 2020, you could say that HFL has undergone a baptism of fire And this is just a brief timeline of what happened next So January, HFL, was launched with our official recognition February, immediately after, I would say around that ministerial stakeholder forum, the government of Liberia initiated its own COVID-19 preparedness response, or preparedness efforts I should say At that time, we had no cases HFL was immediately invited to participate as a private sector counterparts to the Ministry of Health In March 2020, despite intense traveler screening and despite my data quarantining of travelers arriving in Liberia, Liberia recorded its first case of COVID-19 Immediately thereafter, preparedness efforts gave way to response efforts And the private sector engagement committee at the Ministry of Health which Dr. Jabbeh will speak about more, was revived This committee had co leadership by the healthcare federation of Liberia, Liberia Business Association, and the Liberia Chamber of Commerce Next slide So since the initial invitation to the healthcare Federation, to join the incident management system, we have now solidified that to a permanent seat at that meeting We began with this initial advisory liaison role between the private health sector and the larger National COVID-19 meeting But with the launch of the private sector engagement committee, HFL has become a lot more entrenched into the specific technical pillars that are happening within the COVID-19 response, most especially around case management and how COVID-19 cases are being treated, infection prevention and control, risk communications, both within the response and to the general public The laboratory pillar, and then logistics through the newly establish Executive Committee on Coronavirus Next slide Regarding infection, prevention and control One of the first forays for HFL into COVID-19 actual project work, was around IPC Very early on, it became clear that there was a trend of healthcare worker infections in the private sector immediately starting with the first five cases, within the first five or six cases we already had healthcare worker infections happening This was for two reasons The primary reason was that private healthcare facilities are where COVID-19 patients were showing up

And that being combined with a lack of adequate IPC training, or infection prevention control training was leading immediately to healthcare worker infections The government raised an alarm and a call for training of private facilities, but at the time was not yet prepared to launch that training So HFL stepped into the gap, we adapted WHO modules for infection prevention and control to our local context, we sent them to audio lectures, and we offered online virtual training in infection prevention and control that was suited to the Liberian context We quickly then expanded those online trainings into in-person Virtual Training rooms that have limited capacity but offer access to tablets and WiFi, through support with a local advanced telecom company and now through GIZ Dr. Jabbeh, one of our public sector liaison, actually lent her voice to one of the lectures as a voiceover So that was a great piece of public-private collaboration right there Now three months in, we are currently looking to adapt this virtual training format, to meet the new national training format that has been completed for IPC training nationwide So this same format is now going to be used to deliver the content that the government has developed So the collaboration continues We’ve also worked with a partner of ours, Teach for Liberia, which is in collaboration with Teach for All, Teach for America and the others around the world to provide food support for families of affected healthcare workers They had initially started with a program around food support for their students, and then we collaborated with them to provide food supports for healthcare workers, which actually extended beyond our private health care members to the staff of even the national referral hospital, which is the JFK Medical Center, the Liberian Association of medical laboratory technologists, which had several technologists who worked in the national reference lab, who also were affected and became infected And through the National Liberian Medical and Dental Association, who keeps track of and has a welfare committee, to keep track of all the affected health care workers We’ve worked to disseminate official updates from the National Public Health Institute of Liberia, when they are available, even when they are not available though, through our access to the incident management system We’re able to create updates that keep the general public and our membership, up to date with the most recent numbers, healthcare worker infections and whatnot And we also have started to have awareness campaigns just in general around how to protect yourself, effective use of masks and the infectivity of COVID, especially here you see one of the posters that was made with one of our partners, LIB healthline that just shows a general infectivity of using things like public transport Next slide Around case management and the laboratory pillar, we have done quite a bit of technical advisory work there from managements of isolation and treatment units to helping with the validation of the national treatment guidelines, helping with the creation of traveler isolation and screening protocols for the reopening of the airport and around the use of rapid testing and around the establishment of lab facilities even within those treatment units Here you see a picture of one of our low acuity treatment units as it was being finalized So in summary that you could say, Liberia’s case study in public private cooperation or private sector engagement through the healthcare Federation has definitely been a partnership that was forged in fire Right after our inception, we were thrown into a collaboration that has really worked out very well And I definitely see it moving forward in multiple other areas after Coronavirus has left us I will now hand over to my colleague from the Ministry of Health, Dr. Cuallau Jabbeh Howe, who will talk more about that private sector engagement committee through the Ministry of Health Thank you – [Dr. Jabbeh] So I’m Dr. Cuallau Jabbeh Howe, from the Ministry of Health And I’m going to speak a little bit more on the private sector engagement in Liberia and also during the COVID response Next slide Liberia has a long history of public-private partnership

And it all started during the Civil War, we also saw that during Ebola and also we’re now seeing it in the COVID response At first it started as a means of subsidizing health facilities, private sectors to amend the strength of government So the government supporter organizations that were delivering services in health and education out of the different ministries Due to the Corona (mumbles) National Health Plan and strategy In our document, it also outlines the importance of the private-public, public-private partnership Recognizing the critical roles that private sector play in providing services in areas where government is unable to reach For example, the malaria control use, the private sector to increase the uptake of ACT, which is Accessing Combination Therapy that were used to treat malaria in Liberia We also have the ministry to the family health division using the private facilities, to increase uptake of family planning And we’re also recognizing the importance of private sector engagement group during Ebola response We should as (mumbles) self is also in this COVID response That too was a multisectoral group that was made of private health care, business communities, GSM global Excuse me, GSM companies, banking institution also concessions that were helping to strengthen the capacity of the Ministry of Health How did that happen? During the Ebola response, all of the public facilities will close out of fear of contracting Ebola virus And so in the doing that, the private facilities were open, they were serving the population Other importance of those private facilities Government in sort of subsidize them to also help (mumbles) especially (mumbles) during that response Next slide Because of what happened Liberia build a serious resilience and have now able to respond to other outbreaks So when COVID pandemic erupted, Liberia come up prepared and then knew the importance of the private sector And I don’t wanna go into the history, but we know that in like here we have our first case, March 16 and that initiated an Incident Management thing that was set up of which gave rise to the private sector engagement committee, that we are now part of Next slide And was the core that private sector engagement during the COVID Actually it was to strengthen partnership with the private sector In planning, in mobilization in coordination, that will lead to sustainability and effectiveness of the resources, especially for healthcare emergencies including COVID So this parastatal engagement has taught us a lot And we know we are now reaping the benefits And we know how much we have done into this response Next slide As you can see, this is private sector engagement that we establish, and immediately when IMS established this group, we have all of these partners coming on board We have healthcare federation, Liberia Chamber of commerce, and all of the different private benefactors in Liberia Business Association including the concession areas, we also are now on board during the correspondence They are making the strength of the National Public Health Institute of Liberia and the Ministry of Health Next slide So what is this private sector engagement it was doing?

They have been working jointly with the Ministry of Health, the National Public Health Institute, and of course, the Montserrado County Health Team that have most of these cases, and this is where most of the population where 1.7 million population up to 4.8 million lives, Montserrado county, which is the heart of the government, the seeds of the government of Liberia. # Next slide So the establishment The Western objectives in mind to me is for the establishment of the private sector engagement group First of all, we wanted to create an enabling environment to support the response wanted to get all hand on top, wanted to make sure that everyone whether you are public, you are private, you were involved in this response We also needed to leverage the expertise to save lives The private sector has a lot of expertise As you can see with the response, they have been able to more lives, they have connections and all of that And so that was one of the core objective of the engagement of private sector to this response And also to ensure transparency and accountability We know that there were apprehensions, there were mistrust And so we felt that getting our private sectors on board, we will be able and also using them to help the ministry to account for whatever that was brought in to assist in response Next slide What happened (mumbles) response as Nicole mentioned, they had to find a lot very expensive technical assistance Development standard operating procedures, they have also participated in the development of database in order that we did not have the technical expertise to undertake The private sector has also expanded in ambulance fleet for example, the Red Cross They have undertaken due to our low resources, our lack of funding to fund all of the different components of the COVID response They have also participate in the construction of a triage, especially 14 military hospital where we are treating most our COVID victims And they have omitted the strain of the public health sector, bulk supply, donations in kind of medicine, medical supplies, IPC materials, just to name a lot Next slide They have also develop a page for the private sector response as you see, you can log into that and know exactly what is happening They also have a donation platform that accounts for all of the donations that are received on a daily basis And once you logging onto that donation website, (mumbles) daily basis, who brought what in for to assist with the response They are reimbursing private health sector for services rendered, especially the West African platform that is used to respond to the COVID that is referred to as WASCON Next slide We have had some challenges during our engagement with private sector And as we well know there are policy challenges The private sector has their own methods of working and the government have their own standards So to ensure that we have equity among all actors And the we have the private sector on for at least initially from the beginning of planning to help with the national response Also in the Ministry of Health,

we have had practical policy making issues and that was clearly visible during Ebola response, where we had non health and health actors (mumbles) rules So, each one has their own ideas Each one had a new path, their own path, and how to look at, how they respond to carry on And resource allocation There was some hesitation of private sector, for example, they were unclear how government could use new resources that have been brought in# and how they could benefit and also how those resources will be accounted for And of course, the apprehension, some due to fearing for themselves? That fear was how long this pandemic is going to last if I’m going to contribute and what am I gonna gain And that was standing the “not all hands on deck”, but not all of the private sectors were able to come on board due to their own fear of the unknown And of course, as I mentioned the accountability of resources, and if it was not accounted for, we’re actually going to have some issues And how it was going to impact the public health response Accountability also led to transparency challenges How can we at the Ministry of Health track and account for all donations Not only for COVID but also any other donation that will also come pre, post or into our COVID response We also have challenges with financial management, government have issues with inconsistent and delayed fund And so we need a private sector to step in, at some point because government has to mobilize resources internally Unlike the Ebola where, Liberia was being assisted by all of the countries around the world, but this time Liberia had to fend for herself And so as a result, raising funds in country was very difficult and also needed to respond to Ebola to the COVID response (mumbles) and then at that point we had the private sector step in But again, to a kind of concern about the financial management of whatever was coming Next slide Of course, we learn a lot of lessons without public-private partnership through the private sector engagement We know that when there’s an established mechanism, we often get “all hands on deck” So, there was an established mechanism already and the private sector was easily capable to fit in And we know that with policies coming up, established already, we knew that they would also fit in very easily Alignment a collaboration with government’s efforts Government we learned the importance of public-private partnership through the private sector engagement they have omitted the strain of government and this has led better outcomes through this response Transparency and accountability was a challenge both for the private sector being more engaged it has built trust, it has paved way for future engagement They have form permanent solution from this emergency response Aligned motivation, we know that private sector brings a lot of benefits to the health sector, not only through response, but also post response and that we learned during Ebola, after the response, there were a lot of capacity building There were a lot of resources that were left over in that the COVID system was able to use So instead of beginning from scratch, during Ebola response there were a lot of PPEs, a lot of IPC materials left over

that is now being used for the response So private sector engagement does not only stop during an outbreak but also leads to other better outcomes in post response So, these are our partners during the response, who are still here, there are more We have met Silla Mittal, we have like real business association, we have two radio stations who are carrying advocacy, and of course, our health Federation who (mumbles) which is helping with the database to check all donations and a lot more, who do not have (mumbles) Thank you I now turn this over to Ryan – [Ryan] Thank you so much, Dr. Jabbeh And given time folks, we’re going to take about two questions, and then I’ll offer on a final comments So thank you, for those of you who are holding on so far So Amit your question is, how is the reimbursement for private sector services determined? – [Amit] Yeah, that’s a good question It varies from country to country And it also varies from (coughs) insurance and health systems from country to country Usually they do sort of a costing study, what they find is customary and reasonable, then that reimbursement model is negotiated And what’s been the struggle, is to look at the x base level reimbursement by government, and then finding a top up charge that the clients can pay to access private services, simply because, since the input costs of human resources and others in private sector are self funded, as opposed to government, the actual cost to the client will be separate So reimbursement models are based on a costing study and an estimated contractual value of services to the private sector by government insurance schemes – [Ryan] Thank you so much Amit And Dr. Cooper, we have a question for you How can we enhance performance of faith based organization hospitals in the midst of high competition? And what is the role of faith based health facilities in the Africa health care Federation? – [Nicole] So, there is a huge role first of all for faith based healthcare organizations because the healthcare Federation’s represent all private sector players in the health space So all non state actors and that includes faith based and we do have faith based members, even in the healthcare federation of Liberia as new as we are And in terms of (clears throat) excuse me, in terms of how do we improve their performance? I think Liberia and Dr. Jabbeh may be able to speak a little bit about this But Liberia has a very interesting model for performance based financing That is used not only with some faith based facilities, but also with some private sector facilities in general, especially as Dr. Jabbeh mentioned, private sector engagement dates back in Liberia to civil war times And then during Ebola and even post Ebola Where there were times when the Ministry of Health did not have the resources to run even its own facilities at times and those facilities were then subcontracted out to private entities, either NGOs or FBOs So that was one way that the FBOs stepped in to actually collaborate with the public sector, and then their funding or part of their funding, sort of the incentive based funding, was performance based So performance based financing is definitely one strong way to improve the performance of those faith based organizations And I’m not sure if Dr. Jabbeh would like to add anything, but she may be able to expand on that a little bit more – [Ryan] Dr. Jabbeh, would you like to expand on that? – [Dr. Jabbeh] Yes, the faith based organizations like Nicole mentioned, they are very important in especially in our sector here The bulk of our health facilities are run by either the Catholic or the (mumbles) hospital, or of they are run by the Seventh Day Adventist And so if you look at our big hospitals, we start with JFK Medical Center and the county hospitals The big hospitals are run by faith based and so (mumbles) at a time

We know that they have supported us on long way And we know very well that government tried to amend their strength like, for example, we had a BA in Kevin hospital had been subsidized since the war through subsidies provided by government to amend their strength, because if there is any problem the public facilities, part of the population run to the private facilities And so government has been able to subsidize them to help deal with half of the population in Liberia and also to reduce prices for them So we have a good relationship with the private sector, especially faith based organizations in Monrovia, in Liberia, thank you – [Ryan] Thank you, Dr. Jabbeh I’m gonna summarize our last two questions for you, Dr. Nicole … Dr. Cooper, and that is, how do we ensure that resources allocated to the private sector are put to effective use? And what criteria do we use to evaluate which private sector hospitals are utilized? Our final question – [Nicole] So first of all, how do we make sure that resources allocated to the private sector are put to good use I think I refer back to the same performance based financing model because they have a whole list of criteria and accountability monitoring structures that have to be followed Once you’re receiving funding, you must meet these criteria, there will be a review, there’ll be a monitoring team that comes every so often to make sure that x, y and z is in place and we are expecting to see the following results So if we are financing for example, a private facility around maternal child health, we expect to see differences in outcome in that catchment area for maternal child health before and after So I think the answer of how do you make sure that the resources are being used effectively, it’s not through for example, auditing the books, it’s through looking at the outcomes Are the outcomes being achieved? So that is the primary way you do that – [Ryan] Thank you so much Well, thank you, everyone, to the hundred plus people that attended today’s webinar Again, this will be recorded and posted online So we thank you for your participation I want to hand it over to my dear colleague Anna Gerrard to just offer final comments on today’s webinar Thank you – [Anna] Thanks, Ryan I had that (mumbles) appetite practice engagement Liberia And as we move forward with this beyond COVID-19, we’ll keep you informed as to the progress we will make I just wanna say thanks to everyone online for joining and apologies for running over a little bit And thanks to our panelists for their time today Thanks so much – [Ryan] All right, everyone, have a wonderful rest of your day, evening and night Take care