Do Public-Private Partnerships (Ppp) Improve the Delivery of Malaria Care for Under-5 Children in Sierra Leone? a Mixed-Methods Study

Abstract

In 2015, there were an estimated 212 million malaria cases and 429,000 malaria deaths globally; sub-Saharan Africa accounted for more than 90% of cases. In Sierra Leone, malaria is the leading cause of death for children under five years. Despite Sierra Leone’s efforts to integrate malaria interventions with primary health care services for under-five children, gaps remain in availability of services and medicines, resulting in stockouts of drugs and medical supplies and high out-of-pocket cost for services – a situation that was worsened by the 2014 – 2016 epidemic of Ebola virus disease. Public-private partnerships (PPPs) increased in Sierra Leone during this period. This study seeks to understand how one PPP has affected availability of drugs, diagnostics and other essential services and overall delivery of care for malaria in a rural district hospital in Sierra Leone. Using a convergent mixed methods study design, we compared the delivery of malaria care in two public hospitals: Koidu Government Hospital (KGH) – with a PPP between the Ministry of Health and Sanitation and the private non-governmental organization Partners In Health – and the Kenema Government Hospital (KeGH), which is similar but has no PPP support. We combined retrospective analysis of 480 children’s inpatient medical charts and qualitative data from 40 in-depth interviews (20 health care providers and 20 family caregivers) across both hospitals. The proportion of children appropriately tested and treated for malaria was high in both hospitals: 95% at KGH and 97% at KeGH; the percentage of children who had their care impacted by stock out of antimalarials was 0% at KGH and 13% at KeGH((p < 0.0001) Qualitative reinforced these findings: compared to KGH, KeGH had a limited capacity to manage malaria co-morbid conditions due to stockouts of drugs and blood, posing serious economic burden for caregivers. Levels of family caregiver trust and health care worker satisfaction were also higher at KGH in the presence of a PPP. Although both hospitals had high rates of appropriate testing and treating of patients with malaria, the PPP improved ancillary services and strengthened perceptions about quality of health services. We recommend that governments seek creative ways to use PPPs to leverage vertical programs to strengthen overall health service delivery.