ArticlePDF Available

Abstract and Figures

Background Despite progress towards achieving UNAIDS 90–90-90 goals, barriers persist in laboratory systems in sub-Saharan Africa (SSA) restricting scale up of early infant diagnosis (EID) and viral load (VL) test monitoring of patients on antiretroviral therapy. If these facilities and system challenges persist, they may undermine recorded gains and appropriate management of patients. The aim of this review is to identify Public Private Partnerships (PPP) in SSA that have resolved systemic barriers within the VL and EID treatment cascade and demonstrated impact in the scale up of VL and EID. Methods We queried five HIV and TB laboratory databases from 2007 to 2017 for studies related to laboratory system strengthening and PPP. We identified, screened and included PPPs that demonstrated evidence in alleviating known system level barriers to scale up national VL and EID testing programs. PPPs that improved associated systems from the point of viral load test request to the use of the test result for patient management were deemed eligible. Results We identified six PPPs collaborations with multiple activities in select countries that are contributing to address challenges to scale up national viral load programs. One of the six PPPs reached 14.5 million patients in remote communities and transported up to 400,000 specimens in a year. Another PPP enabled an unprecedented 94% of specimens to reach national laboratory through improved sample referral network and enabled a cost savings of 62%. Also PPPs reduced cost of reagents and enabled 300,000 tested infants to be enrolled in care as well as reduced turnaround time of reporting results by 50%. Conclusions Our review identified the benefits, enabling factors, and associated challenges for public and private sectors to engage in PPPs. PPP contributions to laboratory systems strengthening are a model and present opportunities that can be leveraged to strengthen systems to achieve the UNAIDS 90–90-90 treatment targets for HIV/AIDS. Despite growing emphasis on engaging the private sector as a critical partner to address global disease burden, PPPs that specifically strengthen laboratories, the cornerstone of public health programs, remain largely untapped.
Content may be subject to copyright.
R E S E A R C H A R T I C L E Open Access
Role of public-private partnerships in
achieving UNAIDS HIV treatment targets
Ritu Shrivastava
, Peter N. Fonjungo
, Yenew Kebede
, Rajendra Bhimaraj
, Shabnam Zavahir
, Christina Mwangi
Renuka Gadde
, Heather Alexander
, Patricia L. Riley
, Andrea Kim
and John N. Nkengasong
Background: Despite progress towards achieving UNAIDS 9090-90 goals, barriers persist in laboratory systems in
sub-Saharan Africa (SSA) restricting scale up of early infant diagnosis (EID) and viral load (VL) test monitoring of
patients on antiretroviral therapy. If these facilities and system challenges persist, they may undermine recorded
gains and appropriate management of patients. The aim of this review is to identify Public Private Partnerships
(PPP) in SSA that have resolved systemic barriers within the VL and EID treatment cascade and demonstrated
impact in the scale up of VL and EID.
Methods: We queried five HIV and TB laboratory databases from 2007 to 2017 for studies related to laboratory
system strengthening and PPP. We identified, screened and included PPPs that demonstrated evidence in
alleviating known system level barriers to scale up national VL and EID testing programs. PPPs that improved
associated systems from the point of viral load test request to the use of the test result for patient management
were deemed eligible.
Results: We identified six PPPs collaborations with multiple activities in select countries that are contributing to
address challenges to scale up national viral load programs. One of the six PPPs reached 14.5 million patients in
remote communities and transported up to 400,000 specimens in a year. Another PPP enabled an unprecedented
94% of specimens to reach national laboratory through improved sample referral network and enabled a cost
savings of 62%. Also PPPs reduced cost of reagents and enabled 300,000 tested infants to be enrolled in care as
well as reduced turnaround time of reporting results by 50%.
Conclusions: Our review identified the benefits, enabling factors, and associated challenges for public and private
sectors to engage in PPPs. PPP contributions to laboratory systems strengthening are a model and present
opportunities that can be leveraged to strengthen systems to achieve the UNAIDS 9090-90 treatment targets for
HIV/AIDS. Despite growing emphasis on engaging the private sector as a critical partner to address global disease
burden, PPPs that specifically strengthen laboratories, the cornerstone of public health programs, remain largely
Keywords: Public-private partnership, Viral load, Early infant diagnosis, Laboratory systems strengthening, Cascade
* Correspondence:
International Laboratory Branch, Division of Global HIV/AIDS, Center for
Global Health, Centers for Disease Control and Prevention, 1600 Clifton Road
NE, Atlanta, GA 30333, USA
Full list of author information is available at the end of the article
© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (, which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
( applies to the data made available in this article, unless otherwise stated.
Shrivastava et al. BMC Health Services Research (2019) 19:46
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
The Joint United Nations Programme on HIV/AIDS
(UNAIDS) fast track treatment targets call for 90% of
people living with HIV infection to know their status;
90% of those who know their status to receive antiretro-
viral therapy (ART); and 90% of those on ART to
achieve viral suppression by 2020 [1]. Despite significant
progress towards controlling the HIV/AIDS pandemic
[2], these new targets have overwhelmed many public
health laboratory systems in sub-Saharan Africa (SSA)
due to increased demand for early Infant diagnostic
(EID) testing of HIV-exposed infants (HEI) and viral
load (VL) test monitoring of patients on ART [3]. The
VL and EID cascade is characterized by phases from the
point of test request to the use of the test results for pa-
tient management. There are three phases and include
the pre-analytical phase defined as the period from col-
lection of specimens at the referral clinic to receipt of
specimens in the laboratory (includes demand creation
for testing from care providers and patients, specimen
collection and processing, specimen transport system),
the analytical phase defined as the period from testing of
specimens to obtaining results at the laboratory (in-
cludes quality laboratory testing and supply chain man-
agement for test reagents and supplies), and the
post-analytical phase which entails results transmission
from laboratory to receipt of results at the referral clinic
and use for patient management (comprised of result
reporting to clinics, interpretation and uptake for patient
management). Monitoring and evaluation (M&E) is
cross-cutting through the different phases and allows
monitoring of progress of these phases.
Multiple barriers within the VL and EID cascade pre-
vent optimal access and uptake of test results for better
patient management. In the pre-analytical phase, these
barriers include lack of patient awareness for available
HIV test; non-standardized specimen collection prac-
tices, and weak specimen referral networks [4]. In the
analytical phase, challenges include frequent equipment
breakdown, weak supply chain systems, and unsafe bio-
logical waste management. In the post analytical phase,
the challenges experienced comprise delayed and incon-
sistent delivery of test results, limited data systems for
reporting results, and poor clinician utilization of labora-
tory results for improved patient management. There is
also a dearth of adequate numbers of competent work-
force along all phases of the cascade [46].
In 2009 leaders of the US Governments global AIDS
program stated that The problems we face today will be
solved not by governments alone but in partnerships;
partnerships with philanthropy, global business and civil
societies[2]. While global PPPs that have improved
public health programs such as Global Fund, Foundation
for Innovative New Diagnostics, and the Global Alliance
for Vaccines and Immunizations (GAVI), have been
around for decades [7], PPPs that specifically target the
advancement of laboratories, an indispensable compo-
nent of these programs, are rare. The gap persist despite
the increasing emphasis on engaging the private sector
as a critical partner to improve services and systems to
address diseases that are threats to public health [8
11]. One of the reasons for engagement of fewer than
anticipated private entities could be the paucity of em-
pirical data and strategies for effective private sector
engagement [12].
Studies suggests that the influx of donor funding has
led to decreased private contributions for HIV/AIDS.
The reduction in private sector investment and engage-
ment raises concerns about the sustainability of HIV/
AIDS programs, particularly in light of the current glo-
bal economic crisis and emerging competing priorities
[13]. There exist opportunities for partnerships to
strengthen systems in the VL and EID cascade and ad-
dress gaps to accelerate achieving the UNAIDS 90
90-90 goals. SSA countries are at different stages of scal-
ing up VL and EID and have varying challenges [5].
Partnerships, especially PPP can play an important role
in resolving system barriers affecting VL and EID. In this
review, we identify and provide a description of PPPs in
SSA that have been used to resolve systemic barriers
within the cascade and demonstrated its impact in the
scale up of VL and EID.
Data sources and search strategy
We queried five HIV and TB laboratory databases
(Medline, Embase, CINAHL, Global Health, Scopus)
from 2007 to 2017, with an aim to identify
public-private partnerships focused on laboratory sys-
tem strengthening. We used search terms Public
-Private Sector Partnerships, private public partnership,
public private partnership, laboratory or specimen
handling, specimen transport, specimen referral, sample
transport, laboratory quality management, laboratory
worker or laboratory technician. Only articles published
in English were included.
Selection criteria
We used barriers to scale up VL and EID testing cascade
(Fig. 1) as criteria to guide the selection of PPPs in our
review. Records of PPPs that were operational in SSA
and had successfully implemented interventions to im-
prove systems for demand creation for tests, specimen
collection and transportation, laboratory testing, report-
ing laboratory results to clinics were deemed eligible.
A wide spectrum of private sector engagement options
exist for delivery of public health programs [14,15].
PEPFAR defines PPPs as a collaborative endeavors that
Shrivastava et al. BMC Health Services Research (2019) 19:46 Page 2 of 10
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
combines monetary and in-kind resources from the pub-
lic and private sector to accomplish PEPFARsHIV/
AIDS prevention, care, and treatment goals[16]. All
forms of PPP engagements were included in the identifi-
cation step (Fig. 2).
Outcomes of interest and data abstraction strategy
Our search yielded 375 records in EndNoteX7 library,
and eight from non-peer reviewed sources bringing our
total to 383 records (Fig. 2). Using Endnotesfind dupli-
catesfunction we removed 128 duplicates. We system-
atically assessed each record by evaluating the following
broad questions: 1) Was there a clear study objective
that addressed barriers to scale up VL and EID testing in
record? 2) Did the study use the right methods to ad-
dress the study objective? 3) Are the results of the study
valid? 4) Are the results applicable to my population of
interest? Of the 255 remaining articles, 225 records were
removed because of their focus on non-healthcare PPPs.
We tabulated characteristics of the remaining 30 PPPs
by ability of the PPP to address barriers in the various
phases of VL and EID cascade, country of operation,
name of PPP, start year, intervention type, impact and
source using MS Office Excel spreadsheet. Eleven of the
30 abstracts unrelated to laboratory system strengthen-
ing were excluded and leaving 19 full text articles for
review. Thirteen of the 19 articles provided valuable in-
sights into various modes and interpretations of oper-
ationalizing PPPs, benefits and challenges, enabling
factors, reasons for dearth of PPPs in global health care.
We referenced these 13 articles in introduction and
other sections in the manuscript. Six PPP records that
met the eligibility criteria were reviewed and analyzed.
Pioneering PPPs focused on laboratory system
Five of the six eligible PPPs have an international scope
and the other one is an example of a local PPP. Three of
the six PPPs have partnerships with the Presidents
Emergency Plan for AIDS Relief (PEPFAR) program and
the other two are independent of PEPFAR (Table 1).
Memoranda of Understanding (MOUs) were signed
between PEPFAR and three private companies to focus
on strengthening laboratory networks and systems to
support ART scale up. The MOUs were signed between
the US Centers for Disease Control and Prevention
(CDC), Office of Global AIDS CoordinatorPEPFAR
implementing office and three private companies: Bec-
ton Dickinson and Company (BD) [17]; Roche Diagnos-
tics [18] and Siemens Healthineers [19] for $18, $10 and
$15 million, respectively, in shared resources. In 2012,
Fig. 1 Schematic representation depicting different elements of the viral load and early infant diagnosis cascade (Square boxes within the arrow). The
3 major phases (pre-analytical, analytical, post-analytical) of the cascade are delineated within the arrow. Barriers within the different phases of the
cascade are identified above the arrow (dotted line boxes). Public-private partnerships (PPPs) addressing different barrier and at what phase of the
cascade have been identified below the arrow (solid line boxes). Pre-analytical phase defined as the period from collection of specimens at the referral
clinic to receipt of specimens in the laboratory; the analytical phase defined as the period from testing of specimens to obtaining results at the
laboratory and the post-analytical phase entails results transmission from laboratory to receipt of results at the referral clinic and use for patient
management. Siemens =PEPFAR is Stronger Together PPP; Turn Key laboratories =PPP between UNITAID, Roche Diagnostics and Clinton Foundation;
Labs for Life= PPP between Becton Dickinson and Company and PEPFAR; Roche = PEPFAR's PPP with Roche Diagnostics
Shrivastava et al. BMC Health Services Research (2019) 19:46 Page 3 of 10
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
BD and PEPFAR renamed the partnership, Labs for Life,
and renewed it for $20 (20122017) and $12 (2018
2020) million, respectively.
i). Labs for Life (L4L) strengthened access to ART by
building standardized in-country capacity for speci-
men collection, referral and result reporting sys-
tems. With operations in Uganda, Ethiopia,
Mozambique, South Africa, Kenya and India, BD
deployed experts to provide in-country training
(Fig. 1and Table 1).
ii). Roche has three PPPs designated for the VL and
EID programs. In 2008, only 15% of HEI in SSA
were accessing EID services during the first two
months of life [20]. Roche Diagnostics responded
to this critical service gap with a PPP agreement
with UNITAID and the Clinton HIV/AIDS
Initiative (CHAI). Roche provided molecular
diagnostics supplies and set up Turn Key
Laboratories, to provide timely HIV testing for
the pediatric population [20]. In 2012, Roche and
PEPFAR partnered to create capacity for a well-
trained laboratory cadre offering didactic courses
at the Roche Scientific Campus (RSC) in Johan-
nesburg, South Africa. In 2014, Roche signed an-
other landmark PPP, known as the Global Access
Program, which negotiated and lowered the price
of VL tests in low- and middle-income countries
(Fig. 1and Table 1).
iii). Stronger Together is a five-year PPP that was
signed in 2014 between PEPFAR and Siemens
Healthineers, the new brand name of Siemens
Healthcare company. The goal of Stronger To-
getherwas to develop a competent laboratory
workforce globally through a virtual education
platform on social media [21].
iv). Abbott Fund, a global healthcare company,
demonstrated a unique example of a locally
operated PPP in Tanzania in response to the
growing HIV epidemic to rapidly scale up HIV care
and treatment activities. In 2001, Ministry of
Health and Social Welfare (MOHSW) signed a
PPP with Abbott Fund for expanded access to
health care and to strengthen laboratory
infrastructure [22] and system capacity (Fig. 1
and Table 1).
v). Riders for Health PPP was established 25 years ago
in the United Kingdom, and continues now to be
managed out of Africa [15] to address lack of access
to health care among residents in remote
communities in seven countries. Riders for Health
managed a fleet of 1300 motor cycles and a variety
of four wheeled vehicles in harsh conditions with
little infrastructure to connect vital health care with
Fig. 2 PRISMA flow diagram outlining the different stages of literature review search and selection of Public-Private Partnerships (PPP) in
laboratory systems strengthening
Shrivastava et al. BMC Health Services Research (2019) 19:46 Page 4 of 10
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Table 1 Summary of Public-Private Partnerships (PPPs) (20072017) that address barriers and strengthen laboratory systems in
resource-limited settings to improve access, coverage, quality and utilization of Viral Load and Early Infant Diagnosis testing
Barrier Country PPP PPP Intervention Impact Source
Poor and non-
Kenya L4L Trained 91 HCW
on safe phlebotomy
collection practices.
knowledge of
by 41%.
Integration of
safe phlebotomy
practices into
pre-service training.
Kimani, [26]
Weak supply chain
and unreliable
Riders for
Accessed hard-to-
reach communities
for healthcare needs
by providing
motorcycles for
Trained healthcare
workers on
managing supply
chain distribution
of medicines,
of specimens
and return of
results and
managed emergency
Improved access
to 14.5 million people
to healthcare.
Transported 400, 000
between laboratory and
healthcare facilities.
WHO [23,
World Bank
Weak specimen
transportation system.
Uganda L4L Use of GIS to map
efficient sample
referral network.
Provided standardized
specimen transportation
Training of transporters
to safely package
and transport
Ten-fold increase in
referrals of patients
sample with presum
ptive MDR-TB.
94% specimens reached
the national laboratory
within the established
target time of 72 h.
Joloba et al., [27]
Lack of skilled
workforce, modern
laboratory infrastructure
to provide timely and
accurate services to
SSA Global
Engaged manufacturer and
negotiated lower prices for
HIV VL and EID reagents.
300, 000 infants enrolled
into care and treatment.
Provided 900,000 tests
for EID.
•–Projected anticipated
cost savings of $150
million in next 5 years.
Roche Diagnostics
SSA Turn Key
Set upTurn Key Laboratory
for access to pediatric testing.
900,000 tests were
made available.
100 laboratories in
SSA now routinely
offer PCR for EID.
Roche Diagnostics
Mozambique L4L Establishment of national
laboratory quality assurance
program to facilitate stepwise
quality improvement of
laboratory services.
Trained and mentorship
resulted in 18 MOH
qualified auditors and
28 manager/quality
officers capacitated to
manage improvements
of laboratories and
steer towards accreditation.
Skaggs et al., [29]
Tanzania Abbott
Built and modernized 23
regional-level laboratories,
Built outpatient center at
the national hospital serving
1000 patients/day.
Provided mentorship.
10 fold increase (from
110,000 to 1,158,000)
in test volumes in 5 years.
Improved healthcare
services for people
living with HIV and other
chronic diseases across
the country.
Abbott Fund [25]
Shrivastava et al. BMC Health Services Research (2019) 19:46 Page 5 of 10
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
rural areas hitherto unreachable except on foot
vi). Phones for Health PPP was initiated in 2007 with
operations in countries including Kenya, Tanzania,
and Rwanda, leveraging over $3 million annually
[24]. Utilizing mobile phone technologies or
mHealth as tools and platforms for health research
and healthcare delivery [25]. It is a PPP between the
health care software provider Voxiva, the phone
producer Motorola, the telecom company MTN,
the GSMA Development Fund, PEPFAR, CDC
Foundation and Accenture Development
Impact of PPPs addressing barriers to scale up HIV viral
load and early infant diagnostic testing
Taken together, the collective contributions of the six
eligible PPPs have impacted a cost savings of 62%, in-
creased access to 14.5 million patients to healthcare,
transported 400,000 specimens/year, tested 300,000 add-
itional HEI, reduced turnaround time of reporting re-
sults by 50%. The specific contributions of the six PPPs
within the pre-analytical, analytical and post analytical
phases of the VL and EID cascade are highlighted below
(Fig. 1and Table 1).
A. Pre-analytical phase
i). Demand creation for testing: In 2014, when
Global Access Program lowered the price of VL
testing by 40% thereby increasing its affordability
and availability, it was projected that this PPP will
save more than $150 million in costs over the next
5 years [20].
ii). Specimen collection and processing: L4L PPP
made significant progress in improving blood draw
practices by developing and institutionalized a
curriculum for phlebotomists to standardize safe
blood-drawing procedures in Kenya. Following the
initial curriculum training, the average knowledge
increase was 41% for phlebotomists [26], which they
went on to apply in their practices.
Table 1 Summary of Public-Private Partnerships (PPPs) (20072017) that address barriers and strengthen laboratory systems in
resource-limited settings to improve access, coverage, quality and utilization of Viral Load and Early Infant Diagnosis testing
Barrier Country PPP PPP Intervention Impact Source
Post -
Delayed and
delivery of VL
and EID test
results to
Ethiopia L4L Used GIS to map and
network 554 clinic facilities
to laboratories testing for VL,
EID, CD4 and hematology.
Procured 400 standard
specimen transportation
Trained 586 and 81
laboratory and
postal workers,
50% reduction in
TAT (from
specimen collection
to reporting
results) for ART
patients (10 to 5
Standardized training
module used for
training in all
the regions
62% in cost savings for
transporting EID
Reduced TAT from
1 to 2 months
to 510 days.
Kebede et al., [32]
Kiyaga et al. [6]
and Rwanda
for Health
Allowed input
of health data
and transfer to
central database.
Enabled ordering
sending alerts and
download of guidelines.
Enabled access to
training materials.
Facilitated transmission
of results to SMS
Improved access
to knowledge and
information of 50,000
community health workers.
Reduced TAT
for results delivery
Effective monitoring
of mother-to-child
transmission through
EID systems rolled
out to 63 sites
UNAIDS [25],
Fogarty [24]
a = Labs fo r Life;
Abbreviations: L4L Labs for Life, HCW healthcare workers, GIS geographic information system, MDR-TB multidrug resistant tuberculosis, PC R polymerase chain
reaction, SSA sub Saharan Africa, VL viral load, EID early infant diagnosis, ART antiretroviral therapy, MOH ministry of health, TAT turnaround time, WHO World
Health Organization, CD4 cluster of differentiation 4, SMS short message service
Shrivastava et al. BMC Health Services Research (2019) 19:46 Page 6 of 10
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
iii). Specimen transport system: In 2007, Ugandas
effort to control the spread of the deadly
Multidrug-Resistant Tuberculosis (MDR-TB) was
severely limited by weak laboratory network
coupled with inadequate specimen referral and re-
sult reporting system. L4L PPP collaborated with
Ugandan Ministry of Health (MOH), CDC and
local partners to use geographic information system
(GIS) technology to map and strengthen a national
specimen referral system [27]. This resulted in 94%
of specimens reaching the national laboratory
within the established target time of 72 h. This
model later served as the cornerstone for the EID
specimen transportation and result reporting system
and generated a cost savings of 62% and reduced
average turnaround time from 1 to 2 months to 5
10 days [6]. Riders for Health transported 400,000
blood and sputum samples between laboratories
and health centers every year and improved access
to healthcare for 14.5 million people in Gambia,
Kenya, Lesotho, Malawi, Nigeria, Zambia,
Zimbabwe [15,28].
B. Analytical phase
i). Laboratory testing: Roches PPP for Turn Key
Laboratoryintroduced a paradigm shift for
expanding laboratory services for pediatric HIV
patients resulting in 900,000 tests being made
available, an increase of 300,000 infants enrolled
into care and treatment, and Polymerase Chain
Reaction (PCR) testing being routinely provided in
more than 100 laboratories [20].
ii). L4L PPP has also played a significant role in
strengthening Continuous Quality Improvement
(CQI) of laboratories in several SSA countries
including Mozambique, Kenya, Ethiopia, India. In a
joint collaboration, L4L helped MOH Mozambique
program by providing training and mentorship that
resulted in 18 MOH qualified auditors and 28
manager/quality officers capacitated to establish a
national laboratory quality assurance program [29].
iii). In collaboration with CDC Tanzania and partners
such as Design 4 Others and the Association of
Public Health Laboratories, the Abbott Funds
PPP contributed $10 million to building and
strengthening a network of 23 regional-level la-
boratories in Tanzania [25]. These laboratories
provided support for 120 district hospital labora-
tories resulting in improved healthcare services.
Abbott Fund provided mentoring, technical sup-
port, and expertise in the areas of construction,
engineering, infection control, waste management,
information technology, and laboratory manage-
ment [30]. This PPP also built a modern out-
serving over 1000 patients a day for HIV and
non-communicable ailments and the system
strengthening efforts increased by 10 fold labora-
tory tests volumes [31].
C. Post analytical phase
i). Result reporting and interpretation by
clinicians: From 2010 to 2012, L4L, MOH and
CDC partnership in Ethiopia reduced the
turnaround time of laboratory patient results by
50% from 10 to 5 days [32] in 554 (59%) of the 944
districts. The program has demonstrated sustainable
expansion covering 800 (85%) of the 944 districts as
of 2017 and transports specimens for CD4, EID,
chemistry, hematology and TB tests, independent of
the PPP.
ii). Phones for Health PPP enabled health workers to
input health data and transfer them to a central
database, order medicines, send alerts, download
guidelines, and access training materials. In
Rwanda, it empowered practitioners to monitor
antiretroviral drug stocks in real time, and
accelerated the return of CD4 and viral load test
results to remote facilities. In September 2012, 252
of the 457 health facilities were using the electronic
system (> 50% of coverage) [33]. Kenya and other
countries have used the mhealth technology to
transmit laboratory results to mobile phones which
are sent to SMS printers in referring clinics to
utilize for patient management [24,25,3436].
Opportunities for PPPs to scale up HIV viral load and
early infant diagnostic testing
Globally, as of 2016, 70% of people living with HIV
(PLHIV) were diagnosed, 77% of those were on ART,
and 82% of those were virally suppressed [37]. This find-
ing highlights the need for additional synergistic partner-
ships to close the gap in HIV testing, treatment, and
viral suppression. Since 2006, the U.S. has been engaged
in nearly 300 partnerships, which have yielded nearly
$400 million in private sector investment and $335 mil-
lion in funding from PEPFAR [38]. More PPP are needed
Shrivastava et al. BMC Health Services Research (2019) 19:46 Page 7 of 10
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
with a focus to strengthen laboratory systems and net-
works. There are still challenges, for instance, access to
testing, return of laboratory test results to patients, en-
suring quality of testing, develop a cadre of trained
workforce, and present opportunities for collaborations
to increase efficiencies. PPPs can play a key role in ad-
dressing some of these challenges.
a). Uptake of VL and EID test results: To close the
knowledge gap of clinicians (e.g., nurses, midwives,
clinical officers, medical doctors) for the uptake of
viral load test results [39], members of African
Regional Collaborative for Laboratory Technologists
collaborated with Roche-PEPFAR PPP and provided
VL training to nurse leaders from 17 countries in
SSA. The training emphasized the role of nurses in
initiating request for VL testing and utilizing VL test
results for patient management in ART clinics [40].
b). Safe and standardized specimen collection
process: Phlebotomy-related errors account for >
60% of errors in the pre-analytical phase [41] and
can lead to delayed or incorrect results, with unjus-
tifiable costs to patient. Roche-PEPFAR PPP collab-
orated with the US CDC to develop an online
training tool to standardize specimen collection
procedures using an alternate specimen type - dried
blood spots (DBS), to improve access to viral load
testing. The training is accessible at the African So-
ciety for Laboratory Medicine (ASLM) portal in
English, French and Portuguese [42].
c). Quality assured test results to clients:
Strengthening the tiered laboratory network in a
country to expand and ensure access to reliable,
high-quality VL and EID testing services is critical
[39]. US CDC developed a CQI program and
Roche-PEPFAR PPP continue to offer the CQI pro-
gram in its campus in Johannesburg. Average pre-
test scores in five courses for 94 students from 22
countries rose from 12 to 88% (personal communi-
cation, facilitator Anna Murphy, affiliation ASLM).
To develop a sustainable, cost-effective solution for
wider dissemination, Stronger Together PPP repli-
cated the two week long didactic curriculum into
an e-library of 48 training videos, available free of
cost through an innovative e-platform [43]. This ap-
proach has caught the interest of MOH in several
African countries and can also be used to deploy
training materials in any area including VL and
d). Specimen transport and result reporting system:
Innovative strategies such as unmanned aerial
vehicles to pick up specimens and deliver results
within Switzerland (Matternet company) [44] and
in Rwanda and Tanzania (Zipline company) [45] are
examples of technology for use in improving
laboratory-clinic interface. These innovations could
be leveraged to improve delivery of VL and EID re-
sults in similar contexts.
Other unmet needs in the VL cascade represent op-
portunities for new partnerships. The needs are inad-
equate and competent workforce, unsafe disposal of
hazardous waste materials generated due to increased
volume of testing, equipment maintenance, limited data
management options to improve laboratory-clinic inter-
face (Fig. 1).
Benefits of PPP to private and public sector
PPPs provided an avenue for private entities to gain ac-
cess and improved understanding of governments pol-
icies and strategies, which can increase market
knowledge and awareness of national priorities. By en-
gaging in PPPs, the private sector can also benefit the
local workforce by providing increased access to re-
sources; introducing new goods and services; sharing
product/service risks and investments [7], identifying
and increasing local expertise; institutionalizing inter-
ventions; and build sustainable laboratory networks with
regard to public-supported laboratories [32]. From the
public sector perspective, effective PPPs provide add-
itional capabilities, flexibility, skills, resources and fund-
ing, which enhance their ability to respond to the
demands for increased services or scale-up programs of
national importance. Furthermore, at the country-level,
PPPs collaboration can empower countries to mobilize
funds and direct them towards highest priority activities;
facilitate research and development; and improve afford-
able healthcare interventions [12].
Strengths and limitations
This review successfully identified PPPs that have con-
tributed to achieving UNAIDS 9090-90 treatment
goals. While most of the PPP were international, we ob-
served the important role played by local indigenous
PPP and further highlighting the important contribution
of PPPs. We are cognizant of the small number of pub-
lished studies highlighting PPP in laboratory system
strengthening. Nonetheless, their impact remains un-
questionable and underscore the need for more labora-
tory systems and service delivery focused PPP.
Clearly PPP plays a critical role towards achieving the
UNAIDS 9090-90 targets. Despite the growing em-
phasis on engaging the private sector as a critical partner
to address health care systems, PPPs that strengthen la-
boratories, the cornerstone of public health programs re-
main largely untapped. Increased partnerships between
Shrivastava et al. BMC Health Services Research (2019) 19:46 Page 8 of 10
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
public sector and private companies are needed to syn-
ergistically address the challenges of achieving universal
HIV testing, VL and EID scale up. Opportunities for
new local and global PPPs should be harnessed for a
standardized and sustained scale up of VL and EID to
reach the 9090-90 goals.
The authors would like to thank Joanna M. Taliano, librarian at Center for
Disease Control and Prevention, Atlanta, USA for helping in the literature
search. The authors are indebted to Chin-Yih Ou, retired senior officer China
CDC for critically reviewing the manuscript. Authors would also like to ac-
knowledge input of Ellen Sampson, Director, Global Marketing at Siemens
Healthineers and William Magagna, Vice President Virtual Education Solutions
at Siemens Healthineers.
The Presidents Emergency Plan for AIDS Relief (PEPFAR) supported staff who
designed the study; collected, analyzed, and interpreted the findings; and
wrote and reviewed the manuscript.
Availability of data and materials
Data used for this systematic review are available through peer-reviewed ma-
terials cited in the manuscript and can be freely accessed online. The data is
also available upon request from the corresponding authors.
The findings and conclusions in this report are those of the author(s) and do
not necessarily reflect the views of the Centers for Disease Control and
RS, PNF, AK, JNN conceived and designed the study; RS, PNF, AK analyzed
the data; RS, PNF, AK wrote the paper; RS, PNF, YK, RB, SZ, CM, RG, HA, PLR,
AK, JNN interpreted the results, critically reviewed and revised the
manuscript, and approved the final manuscript.
Ethics approval and consent to participate
Not applicable; literature review-based research and not involving human
subjects or human material.
Consent for publication
Not applicable
Competing interests
The authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
International Laboratory Branch, Division of Global HIV/AIDS, Center for
Global Health, Centers for Disease Control and Prevention, 1600 Clifton Road
NE, Atlanta, GA 30333, USA.
Centers for Disease Control and Prevention,
Addis Ababa, Ethiopia.
Roche Diagnostics, Johannesburg, South Africa.
Centers for Disease Control and Prevention, Kigali, Rwanda.
Dickinson and Company, Trenton, NJ, USA.
Africa Centres for Disease
Control and Prevention, Addis Ababa, Ethiopia.
Received: 20 August 2018 Accepted: 20 November 2018
1. UNAIDS. 90-90-90: An ambitious treatment target to help end the AIDS
epidemic. Geneva: Switzerland: Joint United Nations Programme on HIV/
AIDS (UNAIDS); 2014. p. 33.
2. PEPFAR. PEPFAR 3.0 Controlling the Epidemic: Delivering on the Promise of an
AIDS-free Generation 2014.
3. Justman J, Koblavi Deme S, Tanuri A, Goldberg A, Gonzalez L, Gwynn C.
Developing laboratory systems and infrastructure for HIV scale-up: a tool for
health systems strengthening in resource-limited settings. J Acquir Immune
Defic Syndr. 2009;52(Suppl 1):S303.
4. Fonjungo PN, Alemnji GA, Kebede Y, et al. Combatting global infectious
diseases: a network effect of specimen referral systems. Clin Infect Dis.
5. Lecher S, Williams J, Fonjungo PN, et al. Progress with scale-up of HIV
viral load monitoring seven sub-Saharan African countries, January
2015June 2016. MMWR Morb Mortal Wkly Rep. 2016;65:13325.
6. Kiyaga C, Sendagire H, Joseph E, et al. Uganda's New National
Laboratory Sample Transport System: A Successful Model for Improving
Access to Diagnostic Services for Early Infant HIV Diagnosis and Other
Programs. PloS One. 2013; 8(11): e78609.
7. McKinsey and Company. Public-Private Partnerships Harnessing the private
sectors unique ability to enhance social impact, 2009.
8. Peeling RW, Boeras DI, Nkengasong JN. Re-imagining the future of diagnosis of
neglected tropical diseases. Comput Struct Biotechnol J. 2017;15:2714.
9. Fonjungo PN, Osmanov S, Kuritsky J, et al. Ensuring quality: a key consideration
in scaling-up HIV-related point-of-care testing programs. Aids. 2016;30:131723.
10. Asuquo AE, Pokam BD, Ibeneme E, Ekpereonne E, Obot V, Asuquo PN. A
public-private partnership to reduce tuberculosis burden in Akwa Ibom
state, Nigeria. Int J Mycobacteriology. 2015;4:14350.
11. Vian T, Richards SC, McCoy K, Connelly P, Feeley F. Public-private
partnerships to build human capacity in low income countries: findings
from the Pfizer program. Human Resour Health. 2007;5:8.
12. Kostyak L, Shaw DM, Elger B, Annaheim B. A means of improving public health
in low- and middle-income countries? Benefits and challenges of international
publice private partnerships. Public Health. 2017;149:1209.
13. Sulzbach S, De S, Wang W. The private sector role in HIV/AIDS in the context
of an expanded global response: expenditure trends in five sub-Saharan
African countries. Health Policy Plan. 2011;26:i7284.
14. White J, Callahan S, Lint S, Li Helen, Yemaneberhan A. Engaging private health
providers to extend the global availability of PMTCT services Available at: Accessed Dec 2017.
15. Bank W. Public private partnerships for health: PPPs are Here and growing. In:
Africa health Forum Finance and capacity for results; 2013.
16. PEPFAR. Public Private Partnerships. Available at:
partnerships/ppp/. Accessed Jan 2018.
17. Dickinson BC. BD and PEPFAR launch labs for life to strengthen Laboratories in
Regions Heavily Burdened by disease; 2012.
18. Roche. Roche and the US Presidents Emergency Plan for AIDS Relief
(PEPFAR) partner to strengthen laboratories medicine training and
knowledge on the African continent. Available at:
media/store/releases/med-cor-2012-12-04.htm. Accessed Feb 2018.
19. Siemens Healthcare. New Public-Private Partnership Uses e-Learning to
Fight HIV/AIDS Available at:
VCCDs42x4mh. Accessed March 2018.
20. Roche Diagnostics Commitment and Care Across the Globe Making a
world of difference in HIV/AIDS and TB. Available at: https://www.roche.
diagnostics-access.pdf. Accessed March 2018.
21. Healthineers S. PEPFAR Rapid HIV Testing Continuous Quality
Improvement (RT-CQI). Available at:
pepfar-hiv-rtcqi. Accessed 11th June 2018.
22. Massambu C, Mwangi C. The Tanzania ex perience: clinical laboratory
testing harmonization and equipment standardization at different levels
of a tiered health laboratory system. Am J Clin Pathol. 2009;131:8616.
23. Wharton Univ of Penn. Riders for Health. Available at: https://
Accessed Feb 2018.
24. Fogarty International Center. Mobile Health (mHealth) information and
Resources Glob Health Matters. Vol. 8. National Institute for Health:
Fogarty, 2009.
25. UNAIDS. HIV-related Public-Private Partnerships and Health Systems
Strengthening, 2009.
26. Kim ani D, Kamau R, Gadde R, et al. Findings of phlebotomy practices in
Kenya in 2010: need for actio n. (Special Issue: Public-private partnership
and strengthening laboratory systems in Africa.). J Infect Dis. 2016;213:
Shrivastava et al. BMC Health Services Research (2019) 19:46 Page 9 of 10
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
27. Joloba M, Mwangi C, Alexander H, et al. Strengthening the tuberculosis
specimen referral network in Uganda: the role of public-private
partnerships. J Infect Dis. 2016;213:416.
28. WHO for Special Programme for Research and Training in Tropical Diseases
T. Special Programme for Research and Training in Tropical Diseases, TDR.
Available at:
Accessed Feb 2018.
29. Skaggs B, Pinto I, Masamha J, Turgeon D, Gudo ES. Implementing laboratory
quality Management Systems in Mozambique: the Becton Dickinson-US
President's emergency plan for AIDS relief public-private partnership
initiative. J Infect Dis. 2016;213:S4752.
30. Abbott. Improving Access to Healthcare in Tanzania. Available at: https://
healthcare-access-tanzania.html. Accessed December 2018
31. Abbott and Abbott Fund. Elevating Healthcare In Tanzania. Available at:
healthcare-in-tanzania.html-. Accessed Feb 2018.
32. Kebede Y, Fonjungo PN, Tibesso G, et al. Improved specimen-referral system
and increased access to quality Laboratory Services in Ethiopia: the role of
the public-private partnership. J Infect Dis. 2016;213:S5964.
33. Center for Health Market Innovations. TRACnet. Available at: https:// Accessed Feb 2018.
34. mHealth Kenya Public Private Partnership. Leveraging technology to
improve health care outcomes. Available at:
Accessed Feb 2018.
35. Kizito K, Adeline K, Baptiste KJ, et al. TRACnet: a National Phone-based and
web-based tool for the timely integrated disease surveillance and response
in Rwanda. Online J Public Health Inform. 2013;5:202.
36. World Health Organization. Mobile health: transforming the face of health
service delivery in the African Region. Available at: http://www.aho.afro.who.
delivery-african-region. Accessed Aug 2017.
37. UNAIDS. Ending AIDS, progress towards the 9090-90 targets, vol. 2017. p. 32.
38. Goosby E, Zygocki R I. Public-Private Partnerships Are Vital to Creating an
AIDS-Free Generation. Available at:
Accessed April 2018.
39. Trevor P, Ellenberger Dennis KA, et al. Early antiretroviral therapy initiation:
access and equity of viral load testing for HIV treatment monitoring. Lancet
Infect Dis. 2017;17:e26e9.
40. Riley PL, Rurangirwa J, Fowler L, Ellenberger D, Raizes E, Nkengasong NJ.
Nursing and midwifery knowledge, attitudes, and practices towards viral
load testing for managing HIV-infected patients in east, central and
southern Africa. J Midwifery Womens Health. 2016;61:6612.
41. Lima-Oliveira G, Guidi GC, Salvagno GL, et al. Is phlebotomy part of the dark
side in the clinical laboratory struggle for quality? Lab Med. 2012;43:1726.
42. ASLM. HIV Viral Load Scale up Tools. Available at:
viral-load-testing/hiv-viral-load-scale-tools/. Accessed 11th June 2018.
43. Healthineers S. PEPFAR Quality Control and Method Validation. Available at: Accessed June 11
44. Stewart J. Switzerland's Getting a Delivery Network for Blood-Toting Drones.
Available at:
network-for-blood-toting-drones/. Accessed Feb 2018.
45. Forbes. Zipline Is Launching The World's Largest Drone Delivery Network In
Tanzania. Available at:
#11071ef3293b. Accessed Mar 2018.
Shrivastava et al. BMC Health Services Research (2019) 19:46 Page 10 of 10
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Terms and Conditions
Springer Nature journal content, brought to you courtesy of Springer Nature Customer Service Center GmbH (“Springer Nature”).
Springer Nature supports a reasonable amount of sharing of research papers by authors, subscribers and authorised users (“Users”), for small-
scale personal, non-commercial use provided that all copyright, trade and service marks and other proprietary notices are maintained. By
accessing, sharing, receiving or otherwise using the Springer Nature journal content you agree to these terms of use (“Terms”). For these
purposes, Springer Nature considers academic use (by researchers and students) to be non-commercial.
These Terms are supplementary and will apply in addition to any applicable website terms and conditions, a relevant site licence or a personal
subscription. These Terms will prevail over any conflict or ambiguity with regards to the relevant terms, a site licence or a personal subscription
(to the extent of the conflict or ambiguity only). For Creative Commons-licensed articles, the terms of the Creative Commons license used will
We collect and use personal data to provide access to the Springer Nature journal content. We may also use these personal data internally within
ResearchGate and Springer Nature and as agreed share it, in an anonymised way, for purposes of tracking, analysis and reporting. We will not
otherwise disclose your personal data outside the ResearchGate or the Springer Nature group of companies unless we have your permission as
detailed in the Privacy Policy.
While Users may use the Springer Nature journal content for small scale, personal non-commercial use, it is important to note that Users may
use such content for the purpose of providing other users with access on a regular or large scale basis or as a means to circumvent access
use such content where to do so would be considered a criminal or statutory offence in any jurisdiction, or gives rise to civil liability, or is
otherwise unlawful;
falsely or misleadingly imply or suggest endorsement, approval , sponsorship, or association unless explicitly agreed to by Springer Nature in
use bots or other automated methods to access the content or redirect messages
override any security feature or exclusionary protocol; or
share the content in order to create substitute for Springer Nature products or services or a systematic database of Springer Nature journal
In line with the restriction against commercial use, Springer Nature does not permit the creation of a product or service that creates revenue,
royalties, rent or income from our content or its inclusion as part of a paid for service or for other commercial gain. Springer Nature journal
content cannot be used for inter-library loans and librarians may not upload Springer Nature journal content on a large scale into their, or any
other, institutional repository.
These terms of use are reviewed regularly and may be amended at any time. Springer Nature is not obligated to publish any information or
content on this website and may remove it or features or functionality at our sole discretion, at any time with or without notice. Springer Nature
may revoke this licence to you at any time and remove access to any copies of the Springer Nature journal content which have been saved.
To the fullest extent permitted by law, Springer Nature makes no warranties, representations or guarantees to Users, either express or implied
with respect to the Springer nature journal content and all parties disclaim and waive any implied warranties or warranties imposed by law,
including merchantability or fitness for any particular purpose.
Please note that these rights do not automatically extend to content, data or other material published by Springer Nature that may be licensed
from third parties.
If you would like to use or distribute our Springer Nature journal content to a wider audience or on a regular basis or in any other manner not
expressly permitted by these Terms, please contact Springer Nature at
... The Director of Centers for Disease and Control and Prevention (CDC) Africa, Dr. John Nkengasong, described PPPs as a critically important paradigm shift in global infectious disease prevention efforts [21]. Within PEPFAR, there is support from private and public sectors highlighting the valuable role PPPs play when striving to resolve health threats in low-resource settings [22][23][24]. ...
... This innovative evaluation addresses a gap in scientific literature by retrospectively exploring diverse stakeholders' perspectives of PPP implementation experiences relative to inputs, impacts and sustainability potential. The unique contribution of this qualitative investigation captures in-depth perspectives often neglected in evaluative research related to the vantage point of PPP stakeholders with post-implementation experience, especially within the context of strengthening public health laboratory systems and training the workforce in order to catalyze HIV/AIDS intervention scale up goals [1,4,24,52]. ...
... Outcomes included greater operational efficiency, improved communication, and enhanced capacity in terms of the workforce, the laboratory network, and of the public health system. This theme aligns with research supporting that previous PPPs have extended intervention and health care treatment reach, in support of the second 90 UNAIDS' target, resulting in both health system cost-savings and enhanced specimen processing efficiency [24]. In another study, HIV patients gaining access to a private support program sustained by a PEPFAR-PPP resulted in public resource utilization savings and effective viral suppression among enrollees [53]. ...
Full-text available
The global Coronavirus or COVID-19 pandemic exposed the weakness of healthcare systems including laboratory systems and is a call to action for unprecedented collaboration and partnerships to deal with the global crisis. The United States (U.S.) President's Emergency Plan for AIDS Relief (PEPFAR) establishes the global HIV/AIDS treatment agenda in alignment with the UNAIDS 90-90-90 treatment targets to achieve epidemic control related to enhanced testing, treatment, and viral suppression. A strategic PEPFAR priority area recognizes that large-scale collective efforts and sharing of resources bear greater potential impact for lasting change than any single organization or entity can achieve alone. An important vehicle utilized within the global public health context is the public-private partnership (PPP) model whereby multiple international organizations forge unified project charters to collectively reach mutually agreed goals. While touted as an ideal mechanism to synthesize resources and maximize gain in numerous applications, little is known from a seasoned stakeholder perspective regarding PPP implementation and sustainability issues. The purpose of this research is to holistically examine perceptions of PPP model sustainability related to inputs and impacts among a collective network of stakeholders experienced with PEPFAR workforce development, laboratory-system strengthening project implementation. Interviews were conducted with frontline stakeholders from public and private sector organizations based in the US and select PEPFAR-supported priority countries. Analysis revealed three dominant themes: PPP impacts, keys of successful collaboration, and logistical challenges and opportunities to enhance sustainability of PPP outcomes in the future.
... In Africa, 52% of outpatient care seeking occurs in the private sector, including private, for-profit providers, shops, and the informal sector [5]. Literature from HIV/AIDS, routine childhood immunization, child health, malaria, and tuberculosis (TB) highlights the potential of leveraging existing private health facilities (PHFs) to expand access to essential services [6][7][8][9][10][11]. ...
Full-text available
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.
... Despite emphasizing nongovernmental sector participation as an essential partner in disease prevention, participation still requires serious attention to strengthen laboratories. This is consistent with the research results on improving service access, savings costs and time, and improving care indicators (29). Hamzi et al. stated that PPPs had a positive impact on health care delivery, cost savings, and service efficiency; such partnerships satisfied stakeholders with improved access to breast cancer screening, further coverage of dialysis services, and increased access to AIDS policies and programs; they also reduced HIV infection and increased affordability and accessibility to methadone therapy, which is consistent with the results of eight studies concerning improved accessibility (30). ...
Full-text available
Background: The public health system is currently facing a shortage of resources, and the demand for healthcare has increased, indicating the need to use the capacities of other sectors through public-private partnership (PPP) strategies to improve the quantity and quality of health services. Objectives: The purpose is to identify PPPs' role in providing primary healthcare worldwide. Methods: This study was conducted in 2020. The Arksey O’Malley framework was used, along with a systematic literature search on five databases, including Web of Science (ISI), Scopus, Pubmed, ProQuest, and Google Scholar. Data were gathered from 2000 to 2020. Results: The findings presented in this study are reported based on 16 selected studies. The findings point to the positive impacts of cooperation between the public and private sectors in health care systems on matters of provision, coverage, and performance of services, as well as improvements in responsiveness to providers towards enhancing health referral systems. The provision of participatory services in countries varied according to their level of development, and further interactions between the government and the private sector resulted in better coverage and reduced inequality in service delivery. Conclusions: Public-private partnership is an effective way to achieve sustainable development goals. Public-private partnerships can be strengthened by integrating public and private sector facilities and aligning the interests and motivations of service providers with public health goals. Also, awareness of the plans and capacity of public and private sectors, along with conscious and mutual interaction, can strengthen health on a larger scale. Scientific approaches and correct participation can also relieve the part of governmental responsibilities to focus on more primary measures so that it can carry out its core tasks, including stewardship, policy-making, and supervision, with greater focus and power to facilitate the achievement of goals.
... To meet the UNAIDS 90-90-90 treatment target every person starting HIV treatment will need to have access to reliable and timely VL testing and monitoring [24]. Multiple barriers prevent optimal access and uptake of VL test results including delayed and inconsistent delivery of test results to patients, errors due to equipment breakdown, unsafe biological waste management and dearth of adequate numbers of competent workforce [25,26]. The important improvements reported in accuracy and timeliness of HIV VL testing following technical training at ACILT indicates that the participants transferred the knowledge and skills to their home laboratories, with the potential for improved patient outcomes. ...
Full-text available
Background In sub-Saharan Africa, there is dearth of trained laboratorians and strengthened laboratory systems to provide adequate and quality laboratory services for enhanced HIV control. In response to this challenge, in 2007, the African Centre for Integrated Laboratory Training (ACILT) was established in South Africa with a mission to train staffs from countries with high burdens of diseases in skills needed to strengthen sustainable laboratory systems. This study was undertaken to assess the transference of newly gained knowledge and skills to other laboratory staff, and to identify enabling and obstructive factors to their implementation. Methods We used Kirkpatrick model to determine training effectiveness by assessing the transference of newly gained knowledge and skills to participant’s work environment, along with measuring enabling and obstructive factors. In addition to regular course evaluations at ACILT (pre and post training), in 2015 we sent e-questionnaires to 867 participants in 43 countries for course participation between 2008 and 2014. Diagnostics courses included Viral Load, and systems strengthening included strategic planning and Biosafety and Biosecurity. SAS v9.44 and Excel were used to analyze retrospective de-identified data collected at six months pre and post-training. Results Of the 867 participants, 203 (23.4%) responded and reported average improvements in accuracy and timeliness in Viral Load programs and to systems strengthening. For Viral Load testing, frequency of corrective action for unsatisfactory proficiency scores improved from 57 to 91%, testing error rates reduced from 12.9% to 4.9%; 88% responders contributed to the first national strategic plan development and 91% developed strategies to mitigate biosafety risks in their institutions. Key enabling factors were team and management support, and key obstructive factors included insufficient resources and staff’s resistance to change. Conclusions Training at ACILT had a documented positive impact on strengthening the laboratory capacity and laboratory workforce and substantial cost savings. ACILT’s investment produced a multiplier effect whereby national laboratory systems, personnel and leadership reaped training benefits. This laboratory training centre with a global clientele contributed to improve existing laboratory services, systems and networks for the HIV epidemic and is now being leveraged for COVID-19 testing that has infected 41,332,899 people globally.
... Notably, several issues arise in many of these reported partnerships, including the need for thorough communication planning and support from institutional leaders, management of the opportunities and challenges presented by evolving technologies, the difficulties of staff turnover and other workforce development issues, concerns about funding flexibility and sustainability, and consideration of legal and other agreements that may need to be implemented. 5,13,[16][17][18][19][20][21] Public health laboratory partnerships continue to expand and evolve in complexity to meet new and emerging needs. The articles in this supplemental issue of Public Health Reports describe PHL partnerships at the local, state, national, and international levels. ...
Full-text available
Background: The World Health Organization recommended that expanding COVID-19 laboratory testing is one of the disease mitigation mechanisms. In Ethiopia, even though there are few advanced diagnostic laboratories, most of the COVID-19 RT-PCR-based diagnostic laboratory service was provided by public laboratories. This situation creates a major gap in the availability of COVID-19 laboratory testing for the wide public majority and is one of the main challenges in the control and prevention of the disease. Objective: to assess the existing potential for the expansion of COVID-19 RT-PCR-based diagnostic services in private advanced medical laboratories through public-private partnership approaches in Addis Ababa, Ethiopia. Methods: A cross-sectional study was conducted from May to July 2020, among eight private advanced laboratories in Addis Ababa, Ethiopia. A structured questionnaire and on-site observation were made to assess their experiences with molecular laboratory-based diagnostic services, perceived challenges, and their readiness to deliver RT-PCR-based COVID-19 laboratory services on the level of trained laboratory personnel and molecular laboratory setups. Besides, a discussion with government officials on the feasibility of COVID-19 RT-PCR diagnostic services through public-private partnership was made. The collected data were entered and analyzed using SPSS version 20 statistical software. The study was approved by the institutional review board of the College of Health Sciences, Addis Ababa University, and Ethiopian Public Health Institute. Results: Among eight advanced private laboratories, five of the laboratories had previous experience in molecular laboratory testing which includes viral load testing for HIV/AIDS (5/8,). Regarding COVID-19 service readiness, one laboratory had excellent grades towards starting COVID-19 testing; four private laboratories graded as very good and had great interest to provide COVID-19 testing with very minimal support and arrangement with the government bodies. Cost of molecular tests (6/8,), lack of reliable suppliers (6/8,), lack of technical advisors (5/8,) and policy-related issues (4/8) were the major perceived challenges to arranging molecular laboratory testing. Currently Five out of eight, private laboratories are providing RT-PCR-based COVID-19 testing services to the public. Conclusion: In the COVID-19 pandemic era, there is a high possibility of expanding COVID-19 diagnostics services in private diagnostic laboratories through mutual benefit and public-centred discussion between private laboratories and government bodies through public-private partnerships in Ethiopia. This kind of partnership could be a lesson to be considered for any future possible outbreaks, happen to act both public and private Laboratories synergistically. [Ethiop. J. Health Dev. 2022; 36(1)]
Objective The purpose of this study is to see the financing of HIV and AIDS prevention programs in Jayawijaya District, Papua Province. Method This study used a qualitative research design with a case study approach. Results The results of this study indicate that the source of HIV and AIDS prevention programs in the Jayawijaya Health Office comes from the Government (Special Autonomy Fund) and the State Budget (BOK Funds at Puskesmas) and assistance from international NGOs with a very large amount every year. Conclusions This study concludes that HIV and AIDS from the APBN and APBN data should be reviewed to improve with the decreasing number of donor agencies assisting in the Jayawijaya District. So that the HIV and AIDS program in Jayawijaya Regency, Papua Province, is reliable, balanced with a comprehensive coping program strategy.
Full-text available
Мета роботи. Дослідити вплив складових маркетингового підходу до управління інноваційним продуктовим портфелем фармацевтичного підприємства на результативність та економічну ефективність розробок генеричних лікарських засобів (ЛЗ). Матеріали і методи. У якості матеріалів використовували звітні дані про виконані науково-дослідні роботи щодо розробки ЛЗ, звітні дані ВАТ ХФЗ «Червона Зірка» за період 1999–2000 рр. щодо виробництва та збуту ЛЗ, наукові публікації, власні дослідження та результати моніторингу роздрібного ринку ліків компанії «Моріон»; методи: систематизації теоретичного і практичного матеріалу, маркетингового аналізу, порівняльний й економічний методи, метод описового узагальнення. Дана робота має ретроспективний характер. Результати й обговорення. Проведено опрацювання матеріалів щодо маркетингового підходу до удосконалення управління інноваційним продуктовим портфелем при розробці генеричних ЛЗ фармацевтичним виробничим підприємством (ФВП). Проаналізовано комплексний підхід для реалізації інноваційної продуктової політики підприємства та управління продуктовим портфелем. Висвітлено маркетингові складові та їх застосування у комплексному технологічному процесі створення генеричних ЛЗ, постановки на виробництво та виведення їх на ринок. Визначення економічної ефективності проведено на прикладі таблетованих генеричних препаратів диклофенаку, дротаверину (торгова назва Но-Кру-ша), піроксикаму, мазі «Гіоксизон», що одночасно впроваджувались у виробництво. Проаналізовано виробничі та економічні показники 24 серій випуску продукції за 18 місяців. Встановлено, що згідно з ринковим попитом більше 70 % обсягу нової продукції становили таблетки диклофенаку 0,05 г, рентабельність яких склала 88,04 %. Визначено низьку рентабельність (14,19 %) таблеток Но-Кру-ша 0,04 г. Збитковими за досліджуваний період виявились два ЛЗ: таблетки Но-Кру-ша 0,04 г й мазь «Гіоксизон» 15 г. З початку постановки на виробництво та виходу на ринок за 18 міс., що аналізувались, проведено повернення всіх інвестованих коштів та отримано більше одного млн грн додаткового прибутку. При цьому частка прибутку, що генерували таблетки диклофенаку 0,05 г, склала 96,47 %. Висновки. Узагальнено сутність та доцільність комплексного маркетингового підходу до управління продуктовими проектами з розробки ЛЗ. Сформовано блок-схему моделі щодо удосконалення управління продуктовим проектом із розробки ЛЗ на основі маркетингового підходу. Проаналізовано звітні матеріали виробника та фірми-розробника щодо одночасної реалізації кількох індивідуальних проектів інноваційного продуктового портфелю із розробки та виведення на ринок генеричних ЛЗ. Обґрунтовано доцільність та економічну ефективність використання маркетингового підходу у формуванні пріоритетності при плануванні поетапної реалізації індивідуальних продуктових проектів. Розрахунки показали, що маркетинговий підхід дає змогу підвищити ефективність продуктових проектів з розробки ЛЗ та значною мірою використовувати принципи самофінансування та рефінансування.
Full-text available
Neglected Tropical Diseases (NTDs) affect an estimated 1 billion people in 149 countries. The World Health Organization (WHO) prioritised 17 NTDs for control and elimination by 2020 and defined a Road Map to help countries reach these goals. Improved diagnostics for NTDs are essential for guiding treatment strategies at different thresholds of control, interruption of transmission, elimination and post-elimination surveillance. While substantial progress has been made in the last decade with chemotherapy, the same cannot be said of diagnostics, largely due to the perceived lack of a commercially viable market for NTD diagnostics. New sample in-answer out nucleic acid amplification technologies that can be performed at the point-of-care offer improved performance over current technologies and the potential to test for multiple pathogens using a single specimen. Finding commonalities for different NTDs in terms of geographic overlap, sentinel populations and treatment strategy will allow NTD programs to leverage these innovations to build cost-effective multiplex surveillance platforms. Connectivity solutions linking data from diagnostic laboratories and POC test readers/devices provide opportunities for automated surveillance systems to make health systems more efficient, improving patient outcomes and assessing impact of interventions in real time. New models of public?private product development partnerships are critical in leveraging diagnostic innovation in other priority area for better diagnosis, control and elimination of NTDs.
Full-text available
The World Health Organization (WHO) recommends viral load testing as the preferred method for monitoring the clinical response of patients with human immunodeficiency virus (HIV) infection to antiretroviral therapy (ART) (1). Viral load monitoring of patients on ART helps ensure early diagnosis and confirmation of ART failure and enables clinicians to take an appropriate course of action for patient management. When viral suppression is achieved and maintained HIV transmission is substantially decreased as is HIV-associated morbidity and mortality (2). CDC and other U.S. government agencies and international partners are supporting multiple countries in sub-Saharan Africa to provide viral load testing of persons with HIV who are on ART. This report examines current capacity for viral load testing based on equipment provided by manufacturers and progress with viral load monitoring of patients on ART in seven sub-Saharan countries (Cote dIvoire Kenya Malawi Namibia South Africa Tanzania and Uganda) during January 2015-June 2016. By June 2016 based on the target numbers for viral load testing set by each country adequate equipment capacity existed in all but one country. During 2015 two countries tested >85% of patients on ART (Namibia [91%] and South Africa [87%]); four countries tested 80% among those patients who received a viral load test in all countries except Cote dIvoire. Sustained country commitment and a coordinated global effort is needed to reach the goal for viral load monitoring of all persons with HIV on ART.
Full-text available
Background. Nonstandardized specimen logistics, laboratory personnel transporting specimens, no standard specimen containers, and long turnaround time (TAT) hindered access to quality laboratory services. The objective of the Becton Dickinson (BD)-US President’s Emergency Plan for AIDS relief (PEPFAR) Public Private Partnership (PPP) was to support country-specific programs to develop integrated laboratory systems, services, and quality improvement strategies with emphasis on strengthening the Specimen Referral System (SRS). Methods. In 2007, through the Centers for Disease Control and Prevention (CDC), the Ethiopian Public Health Institute (EPHI) joined with the BD-PEPFAR PPP to strengthen laboratory systems. A joint planning and assessment identified gaps in the SRS for prioritization and intervention, and piloted in Addis Ababa and Amhara regions. Results. The PPP established standardized, streamlined specimen logistics using the Ethiopian Postal Service Enterprise (EPSE) to support a laboratory network where 554 facilities referred specimens to 160 laboratories. PPP supported procuring 400 standard specimen containers and training of 586laboratory personnel and 81 postal workers. The average TAT was reduced from 7 days to 2 days in Addis Ababa and from 10 days to 5 days in Amhara region. Conclusions. This study highlights the feasibility and untapped potential of PPP to strengthen laboratory systems. This planned and structured approach to improving specimen referral enhanced access to quality laboratory services. Keywords. specimen referral system; training; public-private partnership; postal system; turn around time
Full-text available
Background. Phlebotomy, a commonly performed medical procedure in healthcare, is essential for disease diagnosis and patient management. However, poorly performed phlebotomy can compromise patient safety, healthcare worker (HCW) safety, and specimen quality. We carried out a study between June and July 2010 to assess knowledge, quality and safety of phlebotomy before implementation of a public-private partnership between Becton, Dickinson and Company and the US President's Emergency Plan for AIDS Relief. Methods. This was a cross-sectional observational study in 8 healthcare facilities within 4 regions of Kenya. HCWs were observed conducting venous and capillary blood collections, and pre- and posttests were offered during HCW training. Results. Of 283 blood samples obtained, 194 were venous draws conducted by 72 HCWs and 89 were capillary draws performed by 33 HCWs. Based on 12 preset quality-associated criteria, none of the 194 observed phlebotomies met the standard. In total, 91 HCWs were trained in phlebotomy. The mean knowledge increase between pre- and posttraining test was 41%, ranging from 39% to 45% (95% confidence interval, 29.3%–53.5%; P < .001). Conclusions. Inadequate knowledge and imperfect phlebotomy procedures were noted. This formed the basis for the safe phlebotomy partnership to address these deficiencies. To ensure sustainability, safe phlebotomy practices were integrated into preservice training.
Full-text available
Background. Mozambique's ministry of health (MOH) recognized the need to establish a national laboratory quality assurance (NLQA) program to improve the reliability and accuracy of laboratory testing. The Becton Dickinson–US President's Emergency Plan for AIDS Relief Public-Private Partnership (PPP) was used to garner MOH commitment and train a cadre of local auditors and managers to support sustainability and country ownership of a NLQA program. Methods. From January 2011 to April 2012, the World Health Organization Regional Office for Africa Stepwise Laboratory Quality Improvement Process Towards Accreditation (SLIPTA) checklist and the Strengthening Laboratory Management Towards Accreditation (SLMTA) curriculum were used in 6 MOH laboratories. PPP volunteers provided training and mentorship to build the capacity of local auditors and program managers to promote institutionalization and sustainability of the program within the MOH. Results. SLIPTA was launched in 6 MOH laboratories, and final audits demonstrated improvements across the 13 quality system essentials, compared with baseline. Training and mentorship of MOH staff by PPP volunteers resulted in 18 qualified auditors and 28 managers/quality officers capacitated to manage the improvement process in their laboratories. Conclusions. SLIPTA helps laboratories improve the quality and reliability of their service even in the absence of full accreditation. Local capacity building ensures sustainability by creating country buy-in, reducing costs of audits, and institutionalizing program management.
Objective: In the last two decades international public-private partnerships have become increasingly important to improving public health in low- and middle-income countries. Governments realize that involving the private sector in projects for financing, innovation, development, and distribution can make a valuable contribution to overcoming major health challenges. Private-public partnerships for health can generate numerous benefits but may also raise some concerns. To guide best practice for public-private partnerships for health to maximize benefits and minimize risks, the first step is to identify potential benefits, challenges, and motives. We define motives as the reasons why private partners enter partnerships with a public partner. Study design: We conducted a systematic review of the literature using the PRISMA guidelines. Method: We reviewed the literature on the benefits and challenges of public-private partnerships for health in low- and middle-income countries provided by international pharmaceutical companies and other health-related companies. We provide a description of these benefits, challenges, as well as of motives of private partners to join partnerships. An approach of systematic categorization was used to conduct this research. Result: We identified six potential benefits, seven challenges, and three motives. Our main finding was a significant gap in the available academic literature on this subject. Further empirical research using both qualitative and quantitative approaches is required. From the limited information that is readily available, we conclude that public-private partnerships for health imply several benefits but with some noticeable and crucial limitations. Conclusion: In this article, we provide a description of these benefits and challenges, discuss key themes, and conclude that empirical research is required to determine the full extent of the challenges addressed in the literature.
The recent Ebola virus outbreak in West Africa clearly demonstrated the critical role of laboratory systems and networks in responding to epidemics. Because of the huge challenges in establishing functional laboratories at all tiers of health systems in developing countries, strengthening specimen referral networks is critical. In this review article, we propose a platform strategy for developing specimen referral networks based on 2 models: centralized and decentralized laboratory specimen referral networks. These models have been shown to be effective in patient management in programs in resource-limited settings. Both models lead to reduced turnaround time and retain flexibility for integrating different specimen types. In Haiti, decentralized specimen referral systems resulted in a 182% increase in patients enrolling in human immunodeficiency virus treatment programs within 6 months. In Uganda, cost savings of up to 62% were observed with a centralized model. A platform strategy will create a network effect that will benefit multiple disease programs.
Scaling up access to HIV viral load testing for individuals undergoing antiretroviral therapy in low-resource settings is a global health priority, as emphasised by research showing the benefits of suppressed viral load for the individual and the whole population. Historically, large-scale diagnostic test implementation has been slow and incomplete because of service delivery and other challenges. Building on lessons from the past, in this Personal View we propose a new framework to accelerate viral load scale-up and ensure equitable access to this essential test. The framework includes the following steps: (1) ensuring adequate financial investment in scaling up this test; (2) achieving pricing agreements and consolidating procurement to lower prices of the test; (3) strengthening functional tiered laboratory networks and systems to expand access to reliable, high-quality testing across countries; (4) strengthening national leadership, with prioritisation of laboratory services; and (5) demand creation and uptake of test results by clinicians, nurses, and patients, which will be vital in ensuring viral load tests are appropriately used to improve the quality of care. The use of dried blood spots to stabilise and ship samples from clinics to laboratories, and the use of point-of-care diagnostic tests, will also be important for ensuring access, especially in settings with reduced laboratory capacity. For countries that have just started to scale up viral load testing, lessons can be learnt from countries such as Botswana, Brazil, South Africa, and Thailand, which have already established viral load programmes. This framework might be useful for guiding the implementation of viral load with the aim of achieving the new global HIV 90-90-90 goals by 2020.
Background. Diagnosis of multidrug-resistant tuberculosis and prompt initiation of effective treatment rely on access to rapid and reliable drug-susceptibility testing. Efficient specimen transport systems and appropriate training on specimen referral contribute to optimal and timely access to tuberculosis diagnostic services. Methods. With support and technical assistance from a public-private partnership (PPP) between Becton Dickinson and the US President's Emergency Plan for AIDS Relief, the Uganda National TB Reference Laboratory (NTRL) and National TB and Leprosy Program redesigned the tuberculosis specimen transport network and trained healthcare workers with the goal of improving multidrug-resistant tuberculosis detection. Results. Between 2008 and 2011, the PPP mapped 93% of health facilities and trained 724 healthcare and postal staff members covering 72% of districts. Strengthening the tuberculosis specimen referral system increased referrals from presumptive multidrug-resistant tuberculosis cases by >10-fold, with 94% of specimens reaching the NTRL within the established target transport time. Conclusions. This study demonstrates the potential of PPP collaborations with ministries of health to positively influence patient care by strengthening laboratory systems through increased access to drug-susceptibility testing in Uganda. Ongoing efforts to integrate specimen transport networks will maximize resources and improve patient management.