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RF_COM_H_67_SUDHA
DFID
Health
Systems
Resource
Centre
“MAKING THE MOST OF THE
PRIVATE SECTOR”
Report of a workshop organised on behalf of the UK
Department for International Development by the
Health Systems Resource Centre with the Health
Economics Financing Programme, London School of
Hygiene & Tropical Medicine
11-12 May 2000
It is now well recognised that the private sector plays a major role in the delivery of
health services in low and middle income countries and that even the poor are paying
large amounts of money to access such services. In many countries the growth of the
private sector has been extremely rapid and largely unregulated. This does offer
potential benefits in terms of providing patients with a wider choice of options,
broadening access to essential services and helping take the strain off the public sector.
However there are major concerns that that many of the services being provided by the
private sector are high cost but low technical quality (and are sometimes even harmful)
and that a growing private sector is undermining Governments' capacity to deliver an
effective safety net for the poor.
Against this background, DFID hosted a meeting In May 2000 to review what is already
known about the performance of the private sector and public private partnerships
(PPPs) with the aim of identifying key lessons and areas where we need to learn more.
Participants were drawn from donor agencies, academia, developing country partners.
and private organisations. The full version of the report, including the presentations, is
now available on the Health Systems Resource Centre's (HSRC) website
The general messages that arose from the meeting were:
•
A more informed policy in relation to the private sector and public private
partnerships will require more intelligence on what the private sector is doing. A
better understanding of the determinants of private sector behaviour and its
performance is needed. More information should be gathered about the impact of
private sector behaviour on the poor and on the nature and impact of interactions
between public and private sectors.
•
Partner Governments can help create an enabling environment by ensuring that
policy towards the private sector is clear, realistic and consistent with broader health
policy. At present in many countries, a far higher standard is set for private providers
than public providers and this sends a clear and negative message to the private
sector. It is important that partner Governments take the lead in developing public
private partnerships. Even where services are being delivered by the private sector.
Government should still set the overall agenda and working through the private
sector should not be seen as a way of bypassing Government bureaucracy
•
Donors can support Governments by helping develop the new skills and the new
ways of working required to support effective partnerships. Key areas where skills
are currently lacking include policy analysis, purchasing or commissioning of
services, setting provider incentives, monitoring and evaluation and the provision of
information to consumers. They can also help by replicating successful pilots
although experience has shown that this rarely happens and we need to critically
review why this has been the case.
•
Expectations of what can be achieved should be high but not unreasonable Whilst
we need to recognise the limitations of such partnerships there is still significant
potential to tap into new areas. On the one hand public private partnership
interventions are unlikely to meet the needs of the poor let alone the very poor and
Governments will have to find other ways of meeting such needs On the other
hand, the private sector could play a larger role in the delivery of essential services if
only the demand was there.
There is a need for Government and donors to jointly identify opportunities for
introducing change and its timing. Reforms may not be politically feasible if vested
interests are allowed time to build up and radical change may only be possible in times
of crisis
In terms of next steps, the main conclusions were to:
•
begin a dialogue on the development of a rapid assessment guideline to help DFID
advisers and ultimately a broader group in developing public private partnerships
•
consider commissioning further work - with a focus on what works where, what are
the limitations, and what experience has been in other sectors - on
r- vouchers, contracting, working with the informal sector, social marketing.
targeting the poor, reconsidering the priority roles of Government, regulation and
learning from other donors' experience host follow up meetmg(s) of UK
practitioners/researchers to get a broader overall picture private sector research
and projects in low and middle income countries and/or to focus on some of the
issues not addressed at this meeting
•
foster better links with other departments within DFID, notably the Governance
Department through informal meetings on governance, enterprise and regulation
issues
Mark Pearson
HSRC
' For information on this and other reports, publications and seminar summaries that are produced by the
DFID Health Systems Resource Centre, please visit our website: http://www.heallhsvslenisrc.oui
Alternatively please contact the HSRC's Information Officer Rabiya Reza either by e-mail
rabiya.reza@ihsd.org or by telephone:
+44 (0)20 7253 2222
The Health Systems Resource Centre is managed for the
Department for International Development by the Institute for Health Sector Development
Tel. +44 (0)20 7253 2222
27 Old Street, London EC1V 9HL
Fax: +44 (0)20 7251 4404 Website: http://www.ihsd.org
C_ o rv\
SID
Society for International Development
Istituto Superiorc di Sanita
Report
International Seminar on
'Global Public-Private Partnerships for Health and
Equity'
November 23 - 24, 2000
Organized by:
the Society for International Development (SID)
World Health Organization (WHO)
Istituto Superiore di Sanita (ISS)
Held at the National Health Council
Rome, Italy
Report on Global Public-Private Partnerships for Health and Equity
Background
Ute International Seminar brought together a group of nearly thirty policy makers.
public health professionals, members of civil society, private foundations and the
private sector from the North and South in order to 'brainstorm' the implications of
public-private partnerships for global public health. The meeting was called in
response to the strong concern raised about the direction and engagement of the
W orld Health Organization in global public-private sector partnerships (GPPPs). The
meeting addressed the successes and failures of public-private partnership in health
looking at the key issues of conflict of interest, governance and the concept of
partnership itself. The meeting took a frank look at the type of new' decision making
processes and institutional arrangements that are required for Wl IO to lead the wav
in ensuring that GPPPs contribute to the global health and equity agenda.
International Seminar Background Papers:
\-Vhv private public partnership’ by Amalia Waxman. NMH/WHO
Global public-private partnerships: part 1 - a new development in health and part 2
what are the health issues for global governance' by Kent Buse and Gill Wall (Bulletin
of the World Health Organization. 2000, 78 (4 and 5)
'Towards a better definition of global 'public-private partnerships for health by Roy
W iddus. Sunil Chacko, Karin Holm and Louis Curt at (Initiative on Public Private
Partnerships for Health Global Forum for Health Research)
Defining partnership
In their opening presentation. Gill Walt and Kent Buse stated that partnerships bring
together a set of actors for the common goal of improving the health of populations
based on mutually agreed roles and principles'. Global public-pi ivale partnerships
are collaborative relationships which transcend national boundaries, bring togethei
at least three parties (amongst them a corporation and an intei-governmental
organization) to achieve a shared health-creating goal, on the basis of a mutually
agreed division of labour.' Roy Widdus, in his presentation on the new forms of
collaboration in health between institutions in the public and private sectors.
identified nearly seventy collaborative relationships that are emerging lor co
ordination and joint act ion for health, particularly to tackle problems more efficiently
or to devise new ways of working on intractable health issues. I It' identified some
major groupings at the global level: public sector programmes with private sectoi
participation, operating under the auspices of intergovernmental agencies, and not
for-profit ‘public-private partnerships' operating under the national laws of various
countries. He undei lined that evaluating collaborative relationships with profit
making groups in areas such as governance, accountability, influence on policy
agendas and representation has to take into account the unique features and
variation among collaborations.
In general, the term ‘partnership’ was questioned. To some participants, the term
■partnership' does not convey adequately the specificity of the new forms emerging.
Some participants felt that while ‘partnership’ is a convenient catch-all term that
conveys a sense of co-operation, it does not capture the diversity of these new. non
traditional relationships. It may also overstate the closeness of collaboration.
according to some participants, because in reality there can be a power differential.
Therefore the degree of shared decision-making and mechanisms to guide the process
2
Report on Global Public-Private Partnerships for Health a11d E.c|u11y
necessary attributes of true partnership - do not always address the problem ol
unequal partners.
As the term partnership has to be continually qualified it is perhaps better to not use
it. Another more cynical perspective expressed was that in today's ideological crisis
the health and development community has moved 'from dignity to rights to fights'
with partnership emerging as the way to manage fights At a minimum, the term
'partnership' may need to be kept in brackets, or defined according to each individual
situation. In this report the term GPPPs is used to mean the set of global collaborative
relationships formed to meet to unmet health needs. Such a definition is underpinned
by the recognition of its limitations in terms of access and equity of health service
provision. GPPPs can be seen as an opportunity, and may be desirable in some cases
but they are not compulsory. A careful matching operation needs to be performed
among the different private and public parties fully aware of the potential benefits or
trade-offs, and of the economic and political context in which GPPPs ate operating.
Setting the questions
The meeting returned to the definition of partnership continually, reflecting the
complexity and newness of the issue. The major focus of the meeting, howevet was
whether GPPPs can or cannot help WHO fulfil its goals. Questions that were
addressed in both the plenary discussion and two sessions of wot king groups
included: how should WHO prepare for GPPPs and maximize potential benefits?
How should the WHO draw the line among the types of GPPPs it should join or
encourage? How does WHO assess if GPPP are delivering benefits for health 01
causing potential harm? Are GPPPs the best way to achieve public health goals? What
are the true cosis of GPPPs to the public sector? What are the possible strategic
alliances among the different types of 'partners' (the multiple stakeholders unions
X'GOs. consumers)? What are the governance mechanisms required to establish
equitable GPPPs? How does one set up the governance struct tires to assess and
monitor the GPPPs as they proceed? How can GPPPs be made more open to civil
society, networks and identity group participation? How can GGGPs build and
support rather than fragment UN and international public health efforts?The
seminar's tentative answers to these questions can be schematically divided into lout
areas: the broad characteristics of GPPPs. governance, conflict of interest and
concrete suggestions to WHO.
Desired characteristics of GPPPs
GPPPs work best when they build on traditional roles of the ■partners': have specific
objectives and agreement on expected outcomes, clearly stated at the outset' operate
with clearly articulated roles and responsibilities ’ground rules : and are implemented
only where all parties agree they will add value.
GPPPs should not aim to create new structures/institutions as an alternative to
legitimate international organizations where a legitimate decision making process
has been established such as in the World Health Assembly. However imperfect tin
WHA may be. this is currently the best way available and most democratic wax
forward.
GPPPs must be dearly defined especially in relation to the ground rules flic- criicria
for participation among each ‘partner' should be openly declared and debated in
terms of how it fits into their organizational values.
3
Report on Global Public-Private Partnerships for Health and Equity
GPPPs need the time and correct process to build up trust and sustainability, to shate
common goals even if partners have different missions. Awareness and openness
about the power differential among ‘partners’ is a sensitive and critical issue, it is
important that GPPPs are not just seen as ways for the public sector io gain [(‘sources
in the short term. A long term perspective demands more than just cherry picking
(the public sector creating GPPPs only when the private sector is willing io allocate
resources). It is important not to have GPPPs that allow the private sector to step into
the space left by the dwindling resources, fragmentation and fragility of public health
services. Nor should GPPPs provide a safety net for political leaders who fail to
provide adequately for the health of their populations.
GPPPs should be as broadly based as possible. It is important to involve appropriate
civil society organizations as a strong ‘partner’ representing consumer concei ns along
w ith public and pro-profit sector interests.
GPPPs are in pari a response to political changes brought about by globalization.
Nations and regions are losing sovereignty to larger global networks. Globalization
imposes new and higher standards of accountability, transparency, and performance
on the health sector and sovereign states to provide adequately for their populations
It is important to take advantage of GPPPs as part of a new mode of integration
beyond traditional spheres -- and this should be done in a way that is compatible and
complementary with the agenda setting function of the UN. In the view of several
participants, some GPPPs may be delegitimizing this function of the UN and should
be challenged.
GPPPs are usually being formed in the 'product' development area, with obvious
potential to benefit health. But participants raised concern where short term profit
making, media attention seeking concerns such as genetic technologies, or selected
disease priorities (TB. Malaria, HIV-A1DS) appeal' to drive the agenda. What needs to
be higher on the list for potential GPPPs are longer term investments that, foi
example, would improve health equity by building capacity in health systems open
up new opportunities for health gains, strengthen institutional arrangements, provide
telemedicine to rural populations, drug development for developing counit v diseases.
improve prevention, reduce harmful risk factors and change consumer habits.
Governance
In order to harness the potential of GPPPs. there was a consensus that clear rules
need to be set down. These should be based on a long term agenda for equity and
health and established through an open and transparent governance sit uctnre
Good governance of GPPPs for global public health requires agreement among all
partners on the formal and informal procedures for:
4
•
membership, participation, representation;
•
cautionary principles and special set of rule to govern conflict.
•
decision-making, enforcement, sanctions, monitoring:
•
roles and responsibilities for the organization and activities of the GPPP:
•
knowledge management;
•
adequate structural capacity;
Report on Global Public-Private Partnerships for Health and Equity
•
resource mobilization and allocation:
•
'exit' clauses for the partners in CPPPs: and
•
development of a self-assessment tool.
It is essential that the decision-making process remains transparent lo all partners in
an\ proposed relationship as well as within the structures of WHO and io non
participants in order to have an open debate of all issues Representatives ol
governments and civil society groups should be included in the process to guarantee
equitable participation of all parties, legitimacy and accountability io the
constituencies the GPPP serves. Everyone has interests or biases, including the public
officials who work in Ministries or agencies like the WHO. 1'his is why transparency
and accountability are important principles for designing and assessing GPPPs.
The criteria for the selection of countries involved in GPPPs needs to be developed
prior to the GPPP. Use of standard economic indicators (like GNP. which is used for
GAV1) and preferential selection of a country may not always be the best sei of
criteria. Accurate indicators of the needs of the people should be evaluated before'
establishing GPPPs and attempts made to avoid inequities within and between
countries involved in the GPPP.
The long-term agenda should be set by a scientific body and aim to build on the sot ial
capital within the GPPP and reconcile public and private goals/pi inciples. li is ol
utmost importance that an agenda is established independently of the weight ol
potential funders in dollars'. The considerable risk of the party with more money
setting the agenda should be avoided.
ftransparency was strongly underlined in the discussions. The decisions leading to a
GPPP need to be in the public domain and must include clarity on why the partners
are entering the GPPP. There should be open acknowledgement of potential areas for
conflict, of interest and information on the funds that are allocated and spent.
Accountability to not only the partners but also to the public was discussed with the
recognition that much more has to be known about the mechanisms foi
accountability of GPPPs as a hybrid institutional form. Every GPPP must have a
public to whom it reports and it must be accountable to a legitimate and democratic
instil ution.
Conflict of interest
The mission of the private and public sector can be kept completely separate from the
shared goal of the GPPP initiative, recognizing that GPPPs can help to overcome
market or public policy failure, mobilize public commitment and build internaliona!
social capital if there is a good governance structure with transparency and
accountability in place.
It may be possible through the GPPP procedure that the private sector is not just a
cash or in-kind donor but also involved in other areas (changes in private secioi
policy for example to come into line with WHO mandate, assisting the public sectoi
in practical management skills and efficacy). This can be an important way to eiisuic
that CPPPs do not exacerbate the fragmentation of international institutions and
work at odds with the scientific and technical agenda set by WI IO for global healih
and equitv.
5
Repoit on Global Public-Private Partnerships for Health and Equity
riti'it' is no consensus on the workability of GPPPS especially in being able io
maintain public sector values. Given the divergence of opinion, it would be helpful loi
the WHO and other UN bodies to support research on how well GPPPs support tin
principles of public health, and review the structure, process and outcomes of GPPPs
(including within the UN). The research would provide historical evidence and solid
analysis on how public health can work best in a globalized world and how in I hat
context GPPPs do or do not improve health services and social development.
Concerns were raised around how the private sector sometimes seems to be using
their involvement in GPPPs solely to promote a positive image through the media.
Raising public awareness of global health issues can be worthwhile but without
concrete actions to back up public campaigns, the promise of GPPPs in health will not
be realized. Participants also noted that short-term output or product, interest of the
private sector can be in conflict with health as a public good, which needs long-tei m
commitment and interest. The public sector needs to understand how the skills of the
private sector can be used as a tool to improve public health. The difference between
the approach of short term, media grabbing, non participatory GPPPs that fragment
rather than strengthen the UN was contrasted with the UN Foundation's approach.
which consolidates on-going mandates of the UN.
An important mechanism to avoid potential conflict of interests or agendas is for the
public sector to take the time to evaluate and assess corporations in a search lot
suitable partners and to be prepared to turn down potential offers from the private
sector if they at e incompatible with the goals of the public sectot.
6
Report on Global Public-Private Partnerships for Health and Equity
Suggestions to WHO
\\ 1 IO. as the leading organization for global public health and equity. must clearly set
the rules of GPPPs within this mandate. It is timely for WHO to step back from the
current situation and reflect on the appropriate role of GPPPs in order to meet public
health and equity needs.
•
WHO needs to set the priorities for agenda setting of GPPPs building on its
technical capacity and scientific knowledge.
•
WHO needs to look al its own governance structures at rhe highest level in
terms of strategic priority setting for GPPPs. It needs to be accountable.
transparent and democratic in its own decision-making processes in order to
have a logical rather than ad hoc approach to GPPPs
•
WHO's Guidelines on the Interaction with Commercial Enterpiises need to be
reviewed and to be placed in a broader conceptual framework that extends
beyond bilateral interactions. The Guidelines have to provide a clear statement
on rules and responsibilities that is transparent internally and externally so
that global multilateral partnerships are inserted into a framework related to
priorities set by WHO.
•
W HO needs to strengthen its capacity to negotiate and engage will) lor profit
and civil society sectors, to be clear when GPPPs are not appropriate and. in
such cases, to be prepared to say 'no' to potential donot s.
•
WHO needs to support research and processes dial
complexities and difficulties of GPPPs.
•
WHO needs to be accountable to the people and listen more to the peoples
needs and in particular the South’s concerns and to empower civil society as an
equal member of a GPPP.
•
WHO needs to monitor on-going procedures of GPPPs and to assess the
activities of potential partners prior to the formation of the GPPP.
•
WHO needs to make long-term projects more appealing (particularly support
for institution strengthening). WHO therefore needs to find new ways io
package and convey public health messages.
will clarify the
7
Report on Global Public-Private Partnerships for Health and Equity
Commitments taken for the follow-up to the meeting
1. To request that the topic of GPPP be placed on the Executive Board Agenda in
January 2001 in order to encourage WHO to consider the issue internally, examining
the evidence for rhe pros and cons of GPPPs. when they are appropriate and when
not. and to define an open process about how to decide for or against part nerships
that goes much further than the present guidelines. The W110 should encourage the
broadest possible range of inputs to this inquiry.
2 To draw up a more comprehensive document that informs WHO guidelines and
takes into account issues of governance, transparency and accountability based on
the discussions and the background papers of Waxman. Wall and Bttse and Widdus.
The process for contribution and shaping of the paper would be open to all interested
parties, taking into account evidence and analysis at the global but also al the
national level.
3. To bring the outcome of the meeting on GPPP including perspectives of the G77 via
the Chair of the I lealih Group into the G8 meeting to be held in Genova in 2001
1. To investigate how to support a systematic process that can addiess the issue
systematically in WHO and with its constituencies particularly involving voices from
the South. One model for that process could be the 'Crucible' group based in Canada
that looked at private public-partnerships with a process that did not request
consensus, laid out and worked with the tensions and conflict of interest and
produced a series of studies and guidelines for GPPP and resulted in a series of high
level consultations and publications.
5. To circulate the report of the meeting through an e-forum in order io continue an
open and transparent debate among the participants.
8
Report on Global Public-Private Partnerships lor Health and E(|tiiiy
Participant list
Dr. Edgar Barillas
GSD Consullores Asociados
Avenida la Reforma 7-62. Zona 9
Edificio Aristosm Oficina 604
Guatemala 01009
Guatemala
Tel: +502 3629271
Fax: -502 3629269
E-mail: edgar@gsd.guate.net
Dr. Giovanni Berlinguer
President
National Committe for Bioethics
Via Veneto. 56
00187 Rome
Italy
Tel: -39 06 48 16 14 90
Fax: +39 06 48 16 1493
E mail: g.berlinguer@palazzochigi.it
Dr. Roberto Bertollini
Director
WHO. Rappresentanza Italia
Via Francesco Crtspi, 10
00187 Roma
Tel: +39 06 48 77 51
Fax: +39 06 48 77 599
E-mail: rbe@who.il
Prof. Kent Base
Yale University School of Medicine
60 College Street
New Haven, CT 06520-8034
USA Canadian
Tel: +1 203 785 2865
Fax: +1 203 785 6193
E mail: kent.buse@yale.edu
Ms. Julie Delahanty
Researcher
RAFI
73 Ch. Juniper
Chelsea. Quebec J9B 1T3
Canada
Tel: +1 819 8279949
Fax: +1 613 5676884
E-mail: jLtlie@rafi.org
Ms Marta di Gennaro
General Secretary
National Health Council
Piazzale dell'Industria 20
00144 Rome
Italy
E-mail: m.digennaro@sanila.ii
Dr. Michael Eriksen
WHO. CDC
20 Ave. Appia
CH-1211 Geneva
Switzerland
Tel: +41 22 7913774
Fax: +41 22 7914186
E-mail: eriksenm@who.int
Dr. Ranieri Guerra
Istituto Superiore di Sanita
Viale Regina Elena. 299
00161 Rome
Italy
Tel: +39 06 49902611
Fax: +39 06 49387073
E-mail: guetra@iss.it
Mr. Rajesh Gupta
Scientist
Partner in Health
20 Ave. Appia
CH-1211 Geneva
Switzerland
Tel: +41 22 791 3224
Fax. +41 22 791 4268
E-mail: guptara@w ho.ch
Dr Wendy Harcourt
Society for International Development
Via Panisperna. 207
00184 Rome
Italy
Tel: +39 06 4872172
Fax: +39 06 4872170
E-mail: wendyh@sidint.org
9
Repo:t on Global Public-Private Partnerships for Health and Equity
Di. Steve Iliffe
I lealth Matteis Magazine
200 Walin Lane
London NW2 3BP
United Kingdom
Tel: t4-1 20 83286164
Fax: -44 20 83288630
E mail: s.iliffe@ucl.ac.uk
Dr Jorge Jimenez de la Jara
Chairman
WHO Executive Board
Departemento de Salud Publica
Marcoleta 352. Casilla 114D
Santiago
Chile '
E-mail: jjimenez@med.puc.cl
Dr. Vittorio Lodolo D’Oria
Bates Italia
Via Paleocapa. 7
20121 Milano
Italv Italian
Tel: -39 02 72223204
Fax: -39 02 7201081!
E mail: lodolo@mbox.calcol.it
Dr. ,-\nke Martiny
Executive Director
Transparency International
Bergham 9
D 8-1104 Rudelzhausen
Germany
Tel: -49 089 48954440
Fax: -19 089 48954442
E-mail: anke.martiny@t-online.de
Dr. Eduardo .Missoni
DGCS. Ministry of Foreign Affairs
Via S. Contarini, 25
00194 Rome
Italv
E-mail: missoni@esteri.it
Mr. C harles Oyaya
Tro p i ca 1 1 n s i i l u t e o f Co m m u n i I y
Health
P.O. Box 60827
Nairobi
Kenva
Tel: +254 2 441046
Fax: -254 2 440306
E mail: iichiibi@net2000ke.com
10
Dr. Kasturi Sen
University of Cambi idge
Public Health and Primary Care
Forvie Site
Cambridge CB2 2SR
United Kingdom
Tel: +44 1223 330300
Fax: +44 1223 330330
E-mail: ks231@hermes.cam.ac.uk
Prof. ChitrSitthi Amorn
College of Public Health
Chulalongkorn Univei si ty
10th Floor. Institute Building
Phythai Rd. Patunwan
Bangkok 10330
Thailand
Tel: + 662 2188185
Fax: +662 2556046
E-mail: chitr@cph.chula.ac.th
Prof. Federico Spandonaro
Facolta di Economia
Univ. Tor Vergata
Via di Tor Vergata
00133 Rome
Italy
Tel: +39 0335 6889057
Fax: +39 06 6685412
E-mail: spandonaro@ecoi iomia.uniroma2.ii
Dr. Angelo Stefanini
University Bologna
Dipt, di Medicina e Sanita Pubblica
Via S. Giacomo, 12
40126 Bologna
Italy
Tel: +39 051 2094815
Fax: 39 051 283252
E-mail: stefanin@alma.unibo.it
Dr. Jeffrey L. Sturchio
Executive Director. Public Affairs
Europe, Middle East & Africa
Merck & Co.. Inc./WS2A 55
One Merck Drive
Whitehouse Station. NJ 08889 0100
USA
Tel: +1 908 423 3981
Fax: +1 908 735 1839
E mail: Jeffrev_st ttrt Tiio@met( It. com
Report on Global Public-Private Partnerships lor Health and Equity
Mr. Juan Eduardo Tello
Istituto Superiore di Sanita
Male Regina Elena, 299
00161 Rome
lialv
Tel:' -39 06 49903345
Fax: -39 06 49387295
E-mail: j.tello@iss.it
Prof. Audrey Gillian Walt
London School of Hygiene and
Tropical .Medicine
Keppel Street
London WCIE 7HT
United Kingdom
Tel: -44 20 79272388
Fax: -44 20 76375391
E-mail: gill.walt.@lslum.ac.uk
Ms Amalia Waxman
WHO
20 Ave. Appia
CH 1211 Geneva
Switzerland
Tel: +41 22 7913353
Fax -41 22 7914186
E-mail: waxmana@who.ch
Dr. Roy Widdus
Manager
Initiative on Public Private
Partnerships for I lealth Global Forum
for Health Research
ICC Block G. Third Floor
20 Route de Pre-[Jois
CH- 1215 Geneva 15
Tel: 41-22-7994086
Fax: 41-22-7994089
E-mail: Roy. widdus@ippph.org
Dr. Derek Yach
Executive Director
WHO Noncommunicable Dis.
20 Ave. Appia
CH-1211 Geneva
Switzerland
Tel: +41 22 791 27 36
Fax: +41 22 7914755
E-mail: yachd@who.im
11
Organized by
Society for International
Development (SID)
Via Panisperna. 207
0018-1 Rome
Italy
Tel: +39 06 4872172
Fax: +39 06 4872170
E-mail: info@siclint.org
Web site: http://www.sidint.org
World Health Organization (WHO)
Avenue Appia. 20
1211 Geneva 27
Switzerland
Tel: +41 22 791 22 11
Fax: +41 22 791 3111
E-mail, info@who.ini
Web site: hnp://w\vw.who.org
Istituto Superiore di Sanita
Viale Regina Elena. 299
00161 Rome
lialv
Tel: +39 06 49902611
Fax: +39 06 49387073
Web site: http://www.iss.it
c. o r-A H - G A-- G
Dr Adetokunbo Lucas is Chair of the Foundation Council
of the Global Forum for Health Research
TDR/BP/00.1
This paper was presented at the Workshop on Public-Private Partnerships in Public Health. Endicott
House. Dedham, Massachusetts,April 7-8th,2000.
This document is not a formal publication of the World Health Organization (WHO), and all rights are
reserved by the Organization.The document may not be reviewed, abstracted, quoted, reproduced or
translated, in part or in whole, without the author’s written permission.
The views expressed in documents by named authors, are solely the responsibility of those authors
©TDR 2000
Correspondence should be addressed to:
Adetokunbo Lucas
17 Acacia Road.
Norbury
London SW16 5PP
UK
ADELUCAS@aol.com
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Background Paper
Public-Private Partnerships:
Illustrative Examples
Adetokunbo Lucas
The World Health Organization, now openly promoting public-private partnerships, has developed a number
of innovative collaborative ventures with the private sector The pioneering work of TDR and some other
special programmes have guided WHO’s bold new approach.The Global Forum for Health Research, whose
major goal is to intensify research effort on problems affecting the poor is also actively promoting public
private partnerships.
In many countries, there are long established links of the public sector with non-governmental organisa
tions and other non-profit institutions in the private sector for the delivery of health care. (Cross. 1998).
On the other hand, until recently, the relationship between the public and the for-profit private sector was
often characterised by antagonism, suspicion and confrontation. For example, the World Health Organiza
tion's (WHO) promotion of the Essential Drug Programme initially provoked strong reactions from the
pharmaceutical industry. Concern about the inappropriate marketing of baby foods in developing countries.
prompted some non-governmental organisations and other activists to mount pressure on manufacturers
of baby foods; this negative reaction also influenced attitudes to the pharmaceutical industry. However, in
recent years, increasing rapprochement between the public and the private sectors, is giving rise to positive
encouragement of public-private partnerships in the health.
In this paper, the term “public-private partnership” is used to refer specifically to the collaborative pro
grammes between the public sector and the for-profit section of the private sector In the rest of the paper,
the term “private sector" will be used to refer to the for-profit, commercial private sector, excluding not-
for-profit non-governmental organisations and institutions within civil society. The paper describes two
illustrative examples of public-private partnerships:
UNDP/World Bank/WHO Special Programme for Research andTraining mTropical Diseases (TDR)
D. Philanthropic drug donation programmes.
A. TDR-AN EXAMPLE OF PUBLIC-PRIVATE COLLABORATION
TDR was established 25 years ago with two inter-related objectives (Godal et al. I 998)
€
Research & Development: to develop safe, acceptable and affordable methods of
prevention diagnosis, treatment and control ofTDR’s target diseases.'
Training & Strengthening: to strengthen the capability of developing disease-endemic
countries to undertake the research required to develop new drugs
'Initially, six groups of diseases were included in the programme: Malaria: Schistosomiasis: The trypanosomiases African trypanosomiasis and Chagas disease:The leishmamases:The filariases - onchocerciasis and lymphatic filariasis:
Leprosy. More recently, dengue and tuberculosis were added to the list of diseases in the TDR portfolio.
tdr/bp/oo I
Background Paper
Co-sponsored by the United Nations Development Programme, the World Bank and WHO. TDR was
clearly a public sector initiative but it collaborated with the private sector on aspects of its programme. It
was clear that TDR could not achieve some of its specific goals, especially the development of new drugs.
without the collaboration of industry. Box I gives an illustrative list of private institutions that were
involved with TDR during the first two decades of its operation. Because of the acrimonious controversies
between the public and the private sectors, TDR's interactions with the pharmaceutical industry were
initially cautious.guarded and closely monitored by the programme’s governing bodies. They kept a watch
ful eye on TDR's links with industry, assuring the sponsors and other interested parties that in all the
contracts and joint activities, the public interest was well protected.
TDR interactions with the private sector included:
Participation of scientists from the pharmaceutical industry in TDR's advisory committees.
® Services to TDR from industry; and
Joint programmes
Box I
TDR’S COLLABORATIONS WITH THE PHARMACEUTICAL INDUSTRY
ACF
I.
Beheer, B.V.. Maarssen, Netherlands
2.
Bayer A.G., Leverkusen. Germany
3.
Biobras-Bioquimica do Brasil, Montes Claros. Brazil
4.
Burroughs Wellcome Company, Research Triangle Park, North Carolina, USA
5.
Ciba Geigy. Ltd., Basle, Switzerland
6.
Daiichi Pharmaceutical Co. Ltd.,Tokyo, Japan
7.
Eli Lilly and Company. Greenfield. Indiana, USA
8.
Genetic Institutes, Boston, Maryland, USA Glaxo Group Research Ltd.. Greenford. UK
9.
IHARABRAS S.A.. Industnas Quimicas. Sao Paulo. Brazil
10.
International Federation of Pharmaceutical Manufacturers Associations. Geneva. Switzerland
I I .Janssen Research Foundation, Beerse, Belgium
12 Laboratorios Gador, Buenos Aires. Argentina
13. Merck and Co. Inc., Rahway, New Jersey. USA
14. E Merck Pharma. Darmstadt, Germany
15 Novo Nordisk A/S, Bagsvaerd, Denmark
16.
Pasteur-Merieux-Connaught, Swiftwater, Pennsylvania. USA
17.
Pharmacia Farmitalia Carlo Elba, Milan. Italy
18.
Rhone-Poulenc Rorer Dorna,Antony, France
19.
SmithKline Beecham Pharmaceuticals, London, UK
2O.Vestar Inc., San Dimas. California, USA
21.
Zeneca Pharmaceuticals. Macclesfield, UK
Source: UNDP/World Bank/VVHO Special Programme lor Research and Training in Tropical Diseases i 1994)
Contributions of scientists from pharmaceutical companies to TDR
TDR used a global network of scientists to develop, implement and review its research and development
projects.The scientists, drawn from academic and research institutes as well as from industry, were selected
strictly on the basis of individual merit and relevance to the needs of the programme.The scientists from
drug companies contributed toTDR's task forces, working groups and steering committees in their special
areas of expertise, but they were not appointed as representatives of their companies.These outstanding
scientists from industry (including two Nobel Prize winners) gave service toTDR on a pro bono basis; they
received no fees or honoraria beyond their travel and subsistence expenses.
2
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Background Paper
Specific Services to TDJR
TDR requested and obtained a variety of services from pharmaceutical companies including.
Special reagents required by research scientists e.g. radio-labelled chemicals.
Good Manufacturing Practice facilities for biological reagents that will be tested in humans e.g.
Armadillo-derived leprosy bacilli,subsequently used for producing test vaccines, were processed and
stored by the Wellcome Research Laboratories on behalf of TDR.
joint activities ofTDR with industry
Drug companies participated with TDR in exploring some promising leads and ideas:
• TDR screening facilities. TDR made available to industry its drug screening facilities. Over 10.000
compounds passed through the network of biological screens for testing candidate drugs for
treatment of onchocerciasis. One compound, ivermectin, proved to be an outstanding product.
C Clinical evaluation.TDR worked with industry in the clinical evaluation of new drugs e.g.
mefloquine (Hoffmann la Roche);ivermectin (Merck.& Co Inc.); eflornithine (Hoechst Marion Roussel
Inc.)
TDR’s research and development effort has been credited with the successful introduction of effective new
technologies. (Box 2).
Box 2
TDR IN A CAPSULE
Since its inception in 1975,TDR’s inputs and outputs include:
- 8000 projects involving 6500 scientists
-
Research & Development
Research Capability Strengthening
5300 projects in 127 countries
2700 projects in 80 countries
totalling US$300 million
totalling US$1 17 million
1100 scientists from developing countries completed research training
- 67 disease control tools developed of which 38 are in use for disease control
- Using tools and strategies generated with TDR support, there is now the possibility that onchocerciasis,
lymphatic filariasis, leprosy and Chagas’ disease can be eliminated
Source:TDR web site http://www.who.int/tdr
Features ofTDR’s partnerships with the private sector
Characteristic features ofTDR’s involvement with industry included the following elements:
Mutual respect. In some international multilateral agencies, political considerations influence the
selection of technical advisers to a degree that compromises the quality of their expert panels.
Distinguished scientists find it difficult to work comfortably in such teams. TDR’s working groups
included distinguished scientists from all over the world: from developed and developing countries;
from both sides of the iron curtain; and from academia, research institutes, health departments as
well as from industry. The realisation that they had been selected on the basis of their personal
expertise facilitated peer-level relationships among the scientists and generated mutual respect for
each other as well as for the programme.
Clear goal orientation. Although TDR supports a wide range of research activities, each group
works towards the achievement of clearly defined goals.The strategic work plans include bench
marks for monitoring progress. Scientists from industry are well adapted co this approach but scien
tists from academia, more used to open-ended type of research plans, also become engaged with the
TDR industrial production approach.
3
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Background Paper.
Sensitivity to each other’s requirements. As a publicly funded programme TDR's activities
had to be transparent for the purpose of accountability to the sponsoring agencies as well as to the
public at large. On the other hand, some of the collaborative research involved information and
intellectual property of commercial value. TDR was able to accommodate both requirements by
providing full disclosure of its operations but arranging for confidentiality on specific matters where
indicated. For example, in screening chemical compounds for industry,TDR agreed to handle coded
samples without requiring the company to disclose the structure of the molecules.
Protecting the public interest. The essence of partnership is joint investment of effort and fair
sharing of rewards. In drawing up contracts with the private sector.TDR pays close attention to the
rights of the public sector to intellectual property that is produced through joint efforts. It has been
possible to obtain various concessions in the public interest such as tiered pricing for sales co the
public sector (e.g. mefloquine) and sub-licensing of patents (e.g. eflornithine). (Box 3)
Box 3
PUBLIC/PRIVATE PARTNERS IN SLEEPING SICKNESS
WHO and Hoechst Marion Roussel Inc. sign a License Agreement allowing WHO to arrange for
the production of eflornithine - the‘resurrection drug’ for African trypanosomiasis.
The initiative involves the drug eflornithine, on which WHO and Hoechst Marion Roussel have collaborated for
a number of years.This drug has been nicknamed the 'resurrection drug’ because of its spectacular effect on
patients in the late stages of the disease, when the patient is comatose. However, although first registered for use
in sleeping sickness in I 990, the drug is not in commercial production, partly because of the limited market,
which makes it not at all attractive to the private sector,and partly due to its expense and hence non-affordability
by endemic countries. On 6 December 1999, the World Health Organization and Hoechst Marion Roussel Inc.
signed a LicenseAgreement, in Geneva.grantingWHO reference right to the license to produce eflornithine.The
agreement will allow technology for production of the drug to be transferred from Hoechst Marion Roussel to
a third party, in the private sector, which will manufacture eflornithine.
Present at the signing was Dr C. Bacchi, who discovered that eflornithine cured trypanosome infection experi
mentally while working under support from TDR, and drew attention to the parasite’s unique polyamine me
tabolism.The drug was originally developed for use in cancer but did not meet expectations; it is now licensed
for use in sleeping sickness in the US. Europe, and 12 African countries.The arrival of eflornithine provided an
alternative drug for the treatment of gambiense sleeping sickness, the form of sleeping sickness that occurs in
west and central Africa; but for the rhodesiense form of sleeping sickness that occurs in central and eastern
Africa, there is no alternative treatment.
The agreement is a response to the challenge of access to drugs to treat diseases of the poor, and illustrates the
new determination ofWHO to'make a difference’.
Source:TDR website — http://www.who.int/tdr
Comment on theTDR experience
TDR's experience with industry shows what can be achieved by carefully designed public-private
partnerships. The relationships have been cordial and productive. TDR’s mandate was to discover and
develop new and improved technologies for the control of tropical diseases affecting the poor in developing
countries. Neither the public sector nor the private sector working alone was able to achieve this goal.
Through public-private partnerships,TDR assembled the critical mass that has produced a steady scream of
new knowledge and effective technologies. Not only have new products emerged, but there is now evi
dence that several of the target diseases are now in the process of being eliminated. (TDR 1997; Blanks et al..
1998)
4
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Background Paper
Special drug donations programmes
Donation of drugs is a well-established charitable activity of private drug companies. Such gifts provide
relief in times of disasters and other emergencies as well as supporting poor countries and their communi
ties. A more recent phenomenon is the donation of specific drugs with explicit major public health goals.
Merck and Co. Inc through their donation of ivermectin (Mectizan), was the pioneer of this new type of
giving.The basis of the donation is summarised in Box 4. (Dull & Meredith, 1998; Fettig, 1998)
Box 4
IVERMECTIN COMES FREE
On 20 June 1986, Robert D. Fluss of Merck Co. Inc.’s Division of International Public Affairs telexed the Director
ofTDR. Adetokunbo Lucas, with this message:
Merck and rhe WHO have collaborated extensively on the development of ivermectin for onchocerciasis.
We are very encouraged by the prospects that this drug will be the first new agent available in several decades
which will allow for the safe and effective treatment of patients on a mass scale. Merck intends to continue to
co-operate with the WHO. the Onchocerciasis Control Programme and endemic country governments, in thenefforts to develop and implement programs so that the drug, when approved for use, can be distributed
efficiently
'The special circumstances associated with this disease and the interest of several organizations and governments
have caused Merck from the outset to consider ways of accommodating a variety of objectives. First and foremost
is ensuring that the drug will be put to optimum use for the benefit of onchocerciasis patients and others who may
be at risk of developing this disease. The company concluded that, in this case, the best way to achieve the full
potential of ivermectin was to ensure that the economic circumstances of patients and governments in onchocer
ciasis-endemic areas would not prevent or restrict widespread use of the product once it is approved. Conse
quently. Merck is undertaking to make appropriate arrangements, if necessary with other interested parties, to
moke needed quantities of the drug available to these governments and patients at no cost to them for
the treatment of onchocerciasis...”
Source: UNDP/World Bank/WHO Special Programme for Research and Training in tropical Diseases (1994)
Charity versus Philanthropy
Andrew Carnegie, the well known philanthropist, in speeches and writings, notably his famous essay on
"The Gospel ofWealth", made a clear distinction between charity and scientific philanthropy. He presented
philanthropy as the mechanism by which “the surplus wealth of the few will become the property of the
many.... administered for the common good,... this wealth can be made a more potent force ...
than if distributed in small sums to the people themselves." He warned that charity could have a
"degrading pampering tendency on the recipients" whereas philanthropy was socially significant and benefi
cial. (Wall. 1970) For the sake of clarity, the first type of donation, consisting of simple random distribution
of largesse, can be rightly described as charity.The donation of ivermectin, involving a clearly defined public
health goal, can be classed as philanthropy. Several other companies have now followed Merck's example in
initiating philanthropic programmes. (Kale, I 999;Wehrwein, 1999) (Table I) (Box 5; Box 6)
Characteristic features of drug philanthropy
The four programmes listed in Table I have three important characteristic features:
Purposeful: In each case, the donation aims at a clearly defined public health goal in terms of a
measurable and significant impact on the target disease.The objectives are described in somewhat ambi
tious terms e.g."Global elimination of lymphatic filariasis”;"lt is possible now that the world can soon end
its fight against blinding trachoma, a war that has been waged for at least 200 years." (See Box 5)
5
Background Paper
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Table I
PHILANTHROPIC DRUG DONATION PROGRAMME
Drug Company
Merck & Co
Public Health
Goal
Programme
Manager
Major Partners*
Mectizan:
Elimination of
Task Force for
• Merck & Co
Onchocerciasis
onchocerciasis
Child Survival &
• Task Force for
Lymphatic filaria
Development
Child Survival &
sis**
(Carter Center)
Drug Target
Diseases
Development
• WHO
• African Pro
gramme for On
chocerciasis
Control
Pfizer
Zithromax:
Elimination of
International
• Pfizer Inc.
Trachoma
blinding trachoma
Trachoma Initiative
• Edna McConnell
Clark Foundation
• WHO
SmithKline
Albendazole:
Elimination of
Beecham
Lymphatic filariasis
Lymphatic filariasis
WHO
• SmithKline
Beecham
• WHO
Glaxo Wellcome
Malarone:
Control of drug-
Task Force for
Malaria
resistant malaria
Child Survival &
• Task Force for
Development
Child Survival &
(Carter Center)
• Glaxo Wellcome
Development-
WHO - Roll Back
Malaria
In each case, many more partners are involved than are shown on these illustrative lists.
An additional commitment by Merck Co. Inc.
Programme: The drug donation is designed as a component of the strategic plan for dealing with
the problem. For example, in the donation of azithromycin for the elimination of trachoma, the
control programme includes four elements, the so-called S.A.EE. strategy Surgery, Antibiotic therapy.
Face washing, and Environmental change (to increase access to clean water and better sanitation.
and to increase health education) (Pruss & Mariotti, 2000)
9 Partnership: Implementation of each programme requires the collaborative effort of several part
ners. (WHO, 1999a) Apart from the national government, partners usually include the donor com
pany. WHO, institutions responsible for programme management, and non-governmental organisa
tions that may undertake drug distribution and other interventions.
6
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Background Paper
Box S
MALARONE DONATION PROGRAMME
A public-private sector partnership between Glaxo Wellcome and the Task Force for Child Survival &
Development, operated in partnership with Ministries of Health.
Objectives
To reduce suffering and deaths from malaria by appropriate use of donated Malarone in endemic areas with
known resistance to standard treatment
»To examine the most effective and responsible method of introducing a new. donated anti-malarial for use in
endemic countries
' To explore ways to develop pubhc/private partnerships for improving the health of people at risk from tropical
disease
Commitments
0 No active commercialisation of Malarone in endemic countries
& Comply with existing malaria control strategies
' Pilot studies to ensure that implementation is practicable and sustainable before expansion
Source: http://www.malaronedonation.org/.
See also: Oyediran & Heisler (1999)
Comment on drug philanthropy
The Mectizan Donation Program has accumulated a decade of experience but the other programmes are
relatively young and are still largely in their formative period. Even at this early stage, it is valuable to ask
critical questions about the concept of drug philanthropy and its implementation. It is relevant to ask some
critical questions at this stage:
t Priorities: Does the programme address a problem of significant public health importance? Or. will
it divert attention and resources away from more important national and regional priorities'
Programme: Is the programme technically sound? Does the drug have an appropriate profile of
features to suit the needs of the programme: efficacy, safety, tolerance, mode of application,
etc.? Does it constitute a significant improvement on the existing package of interventions?
: Prospects: Are the stated goals realistic? Can the distribution of the drug together with the other
planned inputs deliver the expected outcomes? Is there an appropriate infrastructure in place or can
it be developed to support the planned interventions?
These and similar issues need to be addressed in the planning stage of a special donation programme.
Experience gained so far
The Mectizan Donation Program (MDP) has operated long enough for one to undertake a meaningful
review of its functioning and its achievements. (Foege, 1998) Since its inception just over a decade ago, MDP
has enabled over 100 million doses of the drug. Most of the endemic areas of onchocerciasis both in Africa
and in south America are covered. Each year, the programme approves requests for 30 to 40 million treat
ments.
7
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Background Paper
Table 2
Number of Mectizan treatments approved through community based, mass treatment and humanitarian
donation programmes, by year (1988-1999)
Humanitarian*
Total
255,000
26,000
281.000
239.200
1 12,000
351,400
1990
1,321,500
342,500
1,664.000
1991
2,779,800
448,300
3,228,100
1992
4,879,500
509.800
5.389,300
1993
9.050,300
324,600
9.374.900
1994
1 1,801,800
282,200
12,084,000
1995
15,607.700
269,900
15.877,600
1996
19.141,400
159,700
19.301,100
1997
33.725.000
169,500
33,894.500
1998
30,668,500
73.200
30,741,700
1999
29,740,700
1 10,400
29.851,100
159,210,400
2,828,300
162,038,700
YEAR
Community Based
1988
1989
TOTAL
The Humanitarian programme responds to random requests from individual practitioners for use in clinics and in
other institutions.The programme is managed directly by Merck & Co from their Paris office.
Several factors have contributed to the success that MDP has achieved so far;
. An outstanding drug: Mectizan has a profile of good features that make it ideal for mass distribution:
efficacy2, safety, simple regime (single dose by mouth once a year), well tolerated (improved sense of
well being encourages patients to report for repeat doses). Di-ethyl carbamazine (DEC) that was
previously used for treatment of onchocerciasis, provoked reactions in infected eyes, often causing
further damage; ivermectin did not cause such damaging complications and promotes the healing of
early lesions. (Abiose. 1998)
Unequivocal commitment by Merck Co, Inc,The donor company’s commitment is summarised in
the statement: “Providing Mectizan to as many who need it for as long as necessary”
Merck & Co., recently announced an expansion of the Mectizan Donation Programme. In response
to the finding that Mectizan is also effective against lymphatic filariasis, Merck will expand its donation
within Africa for the treatment of lymphatic filariasis.
. Effective Management: TheTask Force for Child Survival and Development has set up an efficient
mechanism for distributing the drug through the health authorities in the endemic countries and
their partners.
Expert GuidanceThe Mectizan Expert Committee, consisting of public health experts, and liaison
persons from Merck and WHO, provides technical guidance to the programme. With this arrange
ment, the donor company keeps in close touch with the programme whilst ensuring that commercial
interests do not interfere with operational decisions.
Mectizan is the most potent anti-infective agent in clinical use; the single adult dose of I2mg once a year com
pares favourably with antibiotics like penicillin and tetracycline that require doses of lOOOmg or more per day!
Mectizan does not kill the adult worm and so it must be given annually to eliminate the larvae.
8
Background Paper
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Guidelines for drug philanthropy
Philanthropy from the pharmaceutical industry is not a new phenomenon.The Wellcome Trust, the largest
medical philanthropic foundation with assets of the order of £13 billion pounds sterling (over US$20
billion), was the product of the munificence of the owner of a pharmaceutical company.Sir Henry Wellcome.
WHO's guidelines for drug donations deal mainly with response to emergencies and some long term
bilateral charitable gifts. (WHO. 1996, 1999b).The first version was issued in May 1996 and represented the
consensus of WHO in consultation with a wide range of organisations.-1 It would be useful to define guide
lines that are appropriate to the philanthropic donations. Such guidelines should include reference to key
features of the philanthropic donations: purposefulness, integration into programmes and the mobilisation
of partnerships.The guidelines should also address the issue of how to develop such programmes when the
donation involves the introduction of a new drug as in the case of ivermectin and malarone.
WHO has drawn up guidelines aimed at reducing inappropriate donations and to guard against abuse.
(WHO, 1999). But these guidelines do not apply to the new philanthropic drug donation programmes. At
the very least, the new guidelines should address the three characteristic features of drug philanthropy:
< Purposeful: defined public health goal; measurable and significant impact:
<: Programme: strategic plan including chemotherapy as a component; and
Partnership: public-private sector collaboration.
The new guidelines should also address some of the issues that have arisen from the experiences that have
been derived from the operation of the four pioneer programmes.
Commitment: the donor company should be willing to make a long-term commitment. (See Box 5)
Such commitment may follow an initial pilot phase.(Box 6)
Box 6
GLOBAL ELIMINATION OF LYMPHATIC FILARIASIS
SmithKline Beecham's Commitment
"SmithKline Beecham will provide albendazole free of charge to WHO for use by governments, and those
organisations working in association with (or with the permission of) these governments, for such duration as
is reasonably designed to achieve the objective ofWHO, expressed in resolution WHA50.29 adopted by the
50th World Health Assembly in 1997 and calling for the global elimination of lymphatic filariasis as a public
health problem. (Since the strategy calls for treatment of all 'at risk' populations annually for 4-6 years, and
since up to 1.1 billion people may be at risk of infection, this donation could comprise as many as 6 billion
doses of albendazole over the lifetime of the elimination effort [estimated at 20-25 years])."
Source:The Collaborative Agreement between SmithKline Beecham and the World Health
Organization Targeting rhe Global Elimination of Lymphatic Filariasis
See Also: WHO (1999)
Churches’Action for Health of rhe World Council of Churches, the International Committee of the Red Cross.
the International Federation of Red Cross and Red Crescent Societies. Medecins Sans Frontieres, the Office of the
United Nations High Commissioner for Refugees, OXFAM and the United Nations Children's Fund. In 1999 the
number of co-sponsors expanded to include Caritas Internationalis, the International Pharmaceutical Federation.
Pharmaciens Sans Frontieres, UNAIDS, the United Nations Development Programme, the United Nations Popula
tion Fund and the World Bank.
9
Background Paper
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Management: Competent, effective management is required to deal with the various aspects of the
programme including mobilisation of and collaboration with partners.
Conflict of Interest: In order to guard against real and apparent conflicts of interest, the system
should include an appropriate buffer between the donor company and the operational decisions.
Each of the four programmes has endeavoured to achieve this objective by handing over the manage
ment to a third party, supported by an independent expert advisory committee. For the Mectizan
Donation Program. Merck devolved decision making to the Mectizan Expert Committee, a group of
scientists and public health practitioners. Merck provided the supplies of Mectizan as recommended
by the expert committee. In order to provide direct charitable contributions. Merck operates a
humanitarian programme from its Paris office; it provides gifts of Mectizan in response to requests
from individual practitioners unrelated to the main programme. (Table 2)
Comments on Public/Private partnerships
The crisis in the health sector has induced governments in many developing countries to review the rela
tionship between the public and the private sectors. Public-private partnerships will become increasingly
more significant in the coming years as policy makers explore options for promoting complementary
involvement of the private sector.
WHO now strongly supports the promotion of public/private partnerships with the caveat that such part
nerships should be mutually beneficial and must always benefit health. (WHO 1998).This new policy of
developing partnerships with the private sector has not gone unchallenged. Some of the activists who have
vigorously campaigned against the private sector have expressed their unhappiness with WHO's new policy
(See Box 7) In spite of these criticisms and reservations, WHO under its new leadership has clearly indi
cated its commitment to work with the private sector. Dr. Gro Brundtland, the Director-General of WHO.
has held roundtable consultations with representatives of the pharmaceutical mdustry.WHO is also engag
ing industry on research projects aimed at finding new medicines for developing countries, on mechanisms
for strengthening the Essential Drug Programme, for combating the illegal traffic in fake medicines, etc
Several ofWHO's new initiatives involve partnerships with the private sector:
C
Roll Back Malaria
ft
Medicine for Malaria Venture
ft
Medicine for African Sleeping Sickness
Box 7
WHO’S NEW GUIDELINES
The industry agenda to co-opt the UN and work in partnership with agencies such as WHO continues to cause
alarm amongst NGOs working to protect public health.With the stakes so high.WHO's new draft Guidelines on
Interaction with Commercial Enterprises, could have an important role to play. The guidelines are, however, very
disappointing and seem to be more an attempt to seek public approval for partnerships with corporations, than to
ensure that WHO stays true to its mandate to improve health. Some good suggestions are made, but the language
used is contradictory and confusing, stressing the need for such things as "mutual respect, trust, transparency and
shared benefit" These concepts hold very different meaning for transnational corporations who have entirely
different aims and values. Commercial enterprises are called on to abide by WHO policies on medicinal drugs.
tobacco and chemical and food safety, but no mention is made ofWHO's infant feeding policies
SOURCE: The website of Baby Milk Action, "a non-profit organisation which aims to save lives and to end the
avoidable suffering caused by inappropriate infant feeding. Baby Milk Action works within a global network to strengthen
independent, transparent and effective controls on the marketing of the baby feeding industry"
10
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Background Paper
UNDP/World Bank/WHO Special Programme for Research & Training in Tropical Diseases
(1997) "Prospects for elimination: Chagas’ disease, Leprosy. Lymphatic filariasis, Onchocercia
sis” (TDR/GEN/97.1).
UNDP/World Bank/WHO Special Programme for Research & Training in Tropical Diseases
(1998) “Tropical Disease Research: Progress 1997-98: Fourteenth Programme Report of the
UNDP/World Bank/WHO Special Programme for Research & Training in Tropical Diseases”,
World Health Organization, Geneva, Switzerland.
Wall J.F. (1970) Andrew Carnegie. University of Pittsburgh Press. Pittsburgh.
Wehrwein P. (1999) Pharmacophilanthropy. Harvard Public Health Review. 32-39 Summer
issue.
World Health Organization (1996) “Guidelines for drug donations”. Geneva:World Health
Organization.WHO/DAP/96.2.
WH.0.(1998) Health For All in the Twenty-First Century World Health Organization Docu
ment A5 1/5 Geneva.
World Health Organization. (1999a) “Building Partnerships for Lymphatic Filariasis”:World
Health Organization, Geneva.
World Health Organization. (1999b) “Guidelines for Drug Donations" (Revised):WHO/
EDM/PAR/99.3: I-23 World Health Organization, Geneva.
Selected web sites
Internet Address
Organisation
Baby Milk Action
http://www.inbc.org/
Global Forum for Health Research
http://www.globalforumhealth.org/
International Trachoma Initiative
http:/www.trachoma.org/abouttrachoma.html
Malarone Donation Programme
http://www.malaronedonation.org/
Mectizan Donation Programme
http://www.taskforce.org/MDP/
Task Force for Child Survival & Development
http://www.taskforce.org/
UNDP/World Bank/WHO Special Programme
for Research and Training in Tropical Diseases
(TDR)
http://www.who.int/tdr
World Health Organization
http://www.who.int/
WHO Control ofTropical Diseases (Filariasis)
http://www.who.int/
13
WHO/TDR
Avenue Appia 20
1211 Geneva 27
Switzerland
Tel: (+41) 22-791-3725
Fax: (+41) 22-791-4854
E-mail: tdi newsi«'vvho.int
Web: www.who.int/tdr
M/BP/00.
Public- Private Partnerships in the Health Sectors:
--An assessment
The definitions:
Different persons use the terms public private partnership and state civil society parteriership with
..
different shades of meaning. Let us define what the way we use the terms private and civil
society
. i < ..
Civil society' we use in the sense of associations of people other than those in government In
practice this often refers to registered societies and trusts involved in health and developmental
work. and peoples movements representing the interests of one or more sections’ However the fr/g
term also includes professional associations, the press, and local community based organisations
like youth clubs, which are not formally registered. There is one important exclusion in this 5.
usage- local self government bodies . These are bodies of local governance and to-be seen-as-part
of the government/state. Due to their lack of powers and resources they may acquire activities and
characteristics similar to a voluntary organisation- but indeed they should not be so confused.
They just need more powers.
The other important exclusion is private companies working for profit. There is an important role
for them and a need for partnership in certain areas which we discuss under public private
partemships, but to prevent confusion we keep that section outside the way we are using civil
society.
When we talk of private we are talking of commercially run organisations driven by the profit
motive, displaying entrepreneurship and facing competition.
Not-for -profit service delivery organisations should also not for this discussion be seen as
private - as they are not defined by the motive of private profit. Neoliberalism believes that
private is better simply because market mechanisms always provide for the greatest efficiency in
service delivery and therefore people would get better health care and cheaper health care too as
long as the market can mediate. The state need only care for the indigent or better still pay their
bills. The discussion below is only examining whether this contention is true.
In contrast to this many use a definition that all those which are not government run - are private.
This confuses two entirely different approaches - it confuses all community based and voluntary
and altruistic efforts with those which are part of corporate strategies of maximising returns on
investment.
The Context of the rise of public private partnerships:
The Alma Ata declaration of 1978 was essentially a political declaration. It recognized the role of
economics and politics, it recognised the role of the state and the need to address inequity and the
need to let people play a central role in decision-making. Its immediate follow up on being
translated into a number of national health policies was also a continuation on this process. In
India for example the national health policy of 1983 was a far-reaching document that captured
much of the spirit of the Alma Ata declaration. What should have followed in the next step was a
greater allocation of funds to health sector, strengthening of district level health administration
and health systems , local health planning efforts, revised health schemes based on locally
identified priorities and schemes that would provide for adequate community involvement. But
this was never to take place -not even at token levels. Instead what took place through the
eighties was a reformulation of the policy into a set of targets and next evolving fragmented
vertical approaches to meet each of these targets.
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28
Enter the World Bank
By 1990 the World Bank had emerged on the scene as the major player and the world
development report as its major expression. The 1990 World Development Report(2) was a
strident advocacy for a greater role in health, (Encouraged iLwent ahead with some serious work
and in 1993 came out with its world development report titled “Investing in Health.”(3) This
report was completely focused on health care and in practice this became international health
policy almost from the day it was published. We shall later examine the compulsions that caused
this, but let us now examine the main features of this report- which was to henceforth inform
almost all national health planning.
The main features of the world banks recommendations in “Investing in Health” were as follows:
1. There is a need to increase public investment in health. This is one of the few
forms of transfer of resources to the poor that is acceptable both because it does
not run foul of local power groups and because it does not increase state role in
the economy.
2. It is not possible to do everything for every body. We ( the world Bank) and
national governments need to prioritise public health interventions. The
mechanism of prioritization is to reduce all diseases to a single index based on
the extent of disability it creates( Disability Adjusted Life Years) and calculate
the expenditure it takes to prevent or cure that disease. Thus prioritization of
public expenditure on health is to be based on “dollar spent per DALY saved.”
3. At the global level the six interventions that emerge as major concerns are
maternal care and child care services, population control, control of tuberculosis,
control of sexually transmitted diseases and nutrition within which micronutrient
intervention was rated the most feasible. Not only these priorities but even the
exact programme design are to be accepted at national level, with some
negotiation if need be before funds needed for building the infrastructure and
implementing the programme could be extended by the World Bank, even then
with strict monitoring and controls.
4. All other dimensions of health must be opened to the private sector and brought
to conform to market forces as competition amongst private producers would
encourage better services at lower costs.
5. Government must reduce its expenditure on other services through cost recovery
mechanisms especially user fees and promote private sector in these areas.
Promotion of health insurance would cover the needs of most sections.
It may also be noted that this World Bank document makes no note of the Alma Ata declaration.
In contrast to the fate of the Alma Ata declaration the implementation of the new World Bank
understanding was immediate. Country after country received a loan, which would be a small part
of the recipient nation’s total health budget but in return for which the health sector had to be
reformed to bring it in conformity with the above principles - structural adjustment in
healthcare!! It is indeed surprising that such a dramatic change did not excite more comment and
opposition especially as many of its immediate implications were technically unsound, politically
unacceptable and even undermined national sovereignty at points. But very soon after the flaws in
this prescription became more and more obvious. Nor was resistance completely absent
especially from more vocal people oriented NGO sections and peoples movements across the
world. And the World bank was quick to respond.
The World Bank Course Correction
Responding to these factors the world bank came out with a modification of its polices which are
set out in its document Nutrition, Health and Population in January 1997.(4).The main features of
this report were as follows
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26
Governments do have a major role to play in health care - especially to reach the
poor. Partly because they(governments) are already there, and also because the
private sector does not reach many of these sections nor include it as their
priorities.
2. The public sector should be much better targeted on specific groups and specific
problems .This needs a number of managerial reforms to improve their efficiency
and the use of specific criteria to identify and define these groups. Even then the
public sector is inherently difficult to reform very much.
3. The private sector is affected by “market imperfections,” causing it to fail to
reach the poor and fail to secure sustainable financing. Unless there is a strong
government role in regulating , assisting and guiding the private sector health
goals would not be achieved.
4. Private voluntary health insurance is particularly prone to market imperfections
and are discouraged.(user fees are not specifically withdrawn but the report
becomes silent on the issue. Subsequently the world Bank is to become vocal
against being characterized as imposing user fees and claim that such
characterization is an example of how it has been misunderstood)
1.
The new mantra becomes “Balanced Public Sector/Private Sector Mix.” To quote-11 Both
economic principles and empirical evidence suggest that a mixture of public and private
involvement leads to the best results in the HNP sector. Neither sector is effective by itself- each
needs the other. Both too much and too little involvement by either sector are often associated
with problems.”(4) (As part of this course correction, the WHO was given a new role, that of a
limited technical adviser and the Alma Ata declaration was acknowledged in the annexure of this
report as a document that had set a number of goals and targets, which was in current need of
updating!!!.)
This retreat from private sector only sort of approach is however not a retreat from neo-liberal
doctrines. Only it is considered a better strategy to attain that goal. The bank advocates three
"waves" of state reform. The first wave focuses on the privatization of commercial enterprises;
die second wave privatizes public infrastructure and utilities; and the third wave continues with
privatization of state assets and utilizes non-governmental and private management and
investment in health, education, and pensions systems.(4) It is privatizing health care in the first
round itself that is being questioned. Moreover the bank is no longer advocating in the health
sector at least for now - the sale of public assets. What they are saying is the use of the public
sector to build up the private sector, in a more viable and sustainable form. In this they see a long
term role for the state too with government having a greater role in the regulation of healthcare
services. Though its health specialists might be eager to play down the bank's support of the
private sector, the latest annual report is less reserved: "One of the bank's top priorities is to help
stimulate the private sector. That's because the private sector is the main source of economic
growth of jobs and higher incomes. The bank encourages the private sector by advocating stable
economic policies, sound government finances, and open, honest, accountable, and consistent
governance, and by offering guarantees."5
Stated Goals of public private partnerships:
Why is public private partnerships preferred? What are the projected benefits?
Broadly these are the following :• They bring in greater efficiency/greater quality in health care service delivery
• They cover areas/sectors where public sector/ cannot or is not efficient to reach.
• They bring in more investment in health.
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23
24
• They bring in more innovation.
• They provide more customer satisfaction..
• They are willing for philanthrophyWe need to examine whether indeed the above contentions can be substantiated by the
experiences of the last five to seven years , once this had become the main thrust of policy. Let us
therefore examine each contention one by one and then look at case studies to see what public
private partnerships are all about.
Better Quality’ of Care:
In a third world context regulatory frameworks are very weak. The private sector in health is
often frankly unethical and irrational. Thus we know that normally about 10% of all pregnancies
are high risk and about 4% would need a Cesarean section. Yet in many private clinics the
Caesarean section rate is about 50%. of all pregnancies . even after accounting for a selection
bias this would be unreasonably high. Unnecessary hysterectomies, appendices removed
unnecessarily, CT scans ordered unnecessarily, laboratory investigations wastefully done and in
so many other ways a supply side driven wasteful and costly consumption of health characterizes
this segment.
The private sector for the poor is another dimension of problems altogether. About two thirds or
more of all private sector care in rural areas are delivered by completely unqualified , illegal
practitioners of allopathy. Many have had as little training as working informally as doctors
assistant in his clinic for one or two months before setting up on their own.
Prescription analysis studies have shown high and dangerous irrationalities in their prescriptions .
The cost of health care is now not only the second highest item of expenditure in all rural
households it is also largely a wasteful drain providing little improvement and often endangering
their health.
Does private sector health care increase outreach?
The state of Chhattisgarh is a good case study for this question. In almost no center where the
public sector has not first penetrated and opened it up to allopathic care - does the private sector
reach. Indeed given the fact that public sector doctors are allowed private practice - the private
sector is embedded in it and spreads with it-never ever proceeding it. In almost a fourth of the
blocks- the public sector doctor is the only qualified medical help available. If we see by sectorsunits of 30,000 population, in over 50% the public sector doctor may be the only doctor available
- even after accounting for a large degree of absenteeism and vacancies. The only other sector
that does have an outreach are some mission hospitals and dispensaries- but they have nothing to
do with all the arguments of privatisation on the world bank. They represent the strengths in civil
society' to resist market forces and their theoretical confusion with the former is a motivated one.
There are studies like Gita Sen’s that have looked at access to health care figures in the nineties
and come to the conclusion that about 35% of population getting excluded from any health care
due to increasing cost of care!!
Public private partnerships are therefore become directed largely to contracting out public paid
services to the private sector.
Let us look at a few case studies of such public- private partnerships:
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Tertiary Care Public Private Partnership
Case Study:
Escorts Hospital and government of Chhattisgarh:
The government of Chhattisgarh signed an MOU with a leading corporate hospital Escorts to
open up a state of the art cardiology center in Raipur , the state capital. The terms were that the
entire infrastructure and equipment and start up costs for this 20 bed facility , which amounts to
115 million rupees would be paid by the state out of its budget. The equipment purchase and
building design and supervision of construction would all be by Escorts. Escorts would further be
allowed to run the hospital, hiring staff of its choice and charging market rates. The running costs
would be all borne by Escorts. Escort would however provide a 15% concession in rates to
government employees and if there are cases the government has to refer the reimbursement of
their fees at this rate would be by the government.
The justification for this is that to bring up such a center within the public sector would be time
consuming and of insufficient quality and would take a lot of effot. But within six months such a
center could be created with this partnership.
While this is true we need to note that we are now talking of good quality in the corporate sense
and what is more important at corporate rates. Is this sort of PPP an argument for better patient
satisfaction we only need note that the state has invested Rs 50 lakh per bed as compared to one
third this amount for an entire 30 bed hospital at the block level catering to one lakh persons with
an outpatient attendance of over 200 persons a day . Such quality care moreover would be
accessible to only a very small section of the elite. The private party has risked very little, brought
in no investment, and it is not very clear how or even whether any transfer of skills would
happen. The moot question is that if we are catering to the most affluent sections why not let the
markeifforces take care of it. Why bring in the state - especially a state which has desperate
levels of poverty and where a large community health worker programme to cover the entire state
cost about the same as a 20 bed hospital and the latter struggles for funds. Or this same budgetaiy
outlay applied annually to the rural public health system can take care of all gaps in staffing at all
levels of paramedicals for the entire state.
This munificence towards the corporate hospital sector has a rich history. Most corporate
hospitals have benefited from special policies meant for its growth. Thus most of them have land
in prime urban areas acquired for them by the government -as a public good - paying for it well
below market rates or not at all. Most of the investment comes in the form of loans from public
sector financial institutions given at terms more favorable then the market rates. They have been
given handsome exemptions from customs duties and tariffs for costly equipment imported. For
all these concessions they were asked to in return provide 10 to 40% of patient care free or
nominally charged so that the poor could benefit. When the Supreme Court was seized of this
issue and ordered an independent investigation by its appointed commissioner Mr. Chandramouli,
the report showed that not a single hospital had honored these commitments. Some of them had
admitted hospital staff family members or occasionally for political patronage perhaps a few
cases. Nothing beyond that.
As the competition hots up it is more than likely that soon many of them would seek and get
counter guarantees. That the state commits to sending a number of patients and paying their bills
in case they find inadequate clientiele through market mechanisms- and in anyway pays them
whether or not they are able to send. In the next iteration there would be a preference to anyway
pay the counter guarantee and not even send patients! If this seems unfair speculation- let us
consider the case of Sheonath river.
1
The Sheonath River Case study .
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32
An entire 23.6 km stretch of Sheonath river in a 19 km radius near Durg township had been
leased out to Radius Water Limited (RWL), giving the Company the monopoly rights on the
supply of water. This was a 22-years renewable concession . The water was to be sold to the
Chhattisgarh State Industrial Development Corporation. This was done by the jdepratmeq of
industries without consultation of legal government stateholders -forests cfeparternnt, water
resources.departments, agriculture department or local governments. Farmers in this stretch of
the river were refused the right to irrigation water, the right to domestic water and fishing nets
put in were cut by henchmenof the new owners of the river moving around in motor boats. The
economics of the deal was that three fourths of the money was put up by the state government.
And whether this accounted for all the money put in due to inflated estimates is open to
question. The company was provided power at special subsidised rates: All that the company
did wa'build a small barrage across the river a fone point.
2$:
Since there was a counter guarantee stipulating that a minimum amount of water would be
purchaseg_by the government over Rs 12 million paid for water not used- for no industry
developed there. And thoughtfully a ten year tax holiday had been provided for. When public
protest forced its reconsideration it emerges for cancellation of the agreement a sum of over 1200
m. rupees would need to be paid!!!! With promise of more contracts.
We may protest that the above is a scam and not a legitimate case to argue about- for the
problems of governance need to be seen separately. But then what did undermine the public
sector in the first place - if not the very same problems of governance. If these wer handled
would private sector prove most cost effective or even quality effective?
Indeed it seems more than likely that public private partner ships are used by larger corporates
with deeper pockets to leverage themselves ahead of their competition usig the mechanisms of the
state. So not only does it not obey the mythical rules of the market, it actually undermines them:
The Central American Case Study: Selling Soap
One example recently published(6) titled” the story of a successful public-private partnership in
Central America” is worth quoting in length. The programme objective is diarrhoeal disease
control and the immediate objective is promotion of handwashing. The approach is for the state to
identify leading manufacturers of soap ,provide them with good market analysis and support for
advertisement campaigns, and then evaluate to see whether the desired effect was gained. The
private soap manufacturers were to integrate health messages as part of their soap promotion
campaign in which they promote their brand of soap, utilize all the resources and technical
knowhow being provided to them, expand their distribution network and watch the profit roll in.
The project identified 10 soap producers and of them two were multinationals, both of whom
joined in and benefited. The report states that they expanded the programme to cover all school
children popularized their brands, were very positive about the out comes and planned to extend
the idea to other areas and commodities. Two of the ten companies were regional of which one
joined in only to drop out later and still later be acquired by the multinational. The remaining six
were local of which two joined in “out of fear of staying out” and the report is strangely silent on
how they benefited from it and whether all they were keen on or able to follow up. The report
notes that the large multinational manufacturers had sought an exclusive relationship and this was
refused. However in the course of everyone being allowed in and the market allowed to play its
role, to no ones surprise the multinationals have come out of it with huge gains. Smaller
producers could certainly not have matched the large number of free soaps that Colgate is stated
to have made available!! And unstated in the report is the probability that the public expenditures
were in the form of World Bank loans, which shall indebt the state into the indefinite future!!
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20
Though no where is private sector stated to be synonymous with corporate sector, we need to
examine how many success stories of private-public mix are stories of the multinational corporate
sector expanding its influence, possibly in the process marginalizing local industry, with liberal
assistance from the public funds. It remains a question that if indeed the magic of the market
place is valid why a giant like unilever did not make the additional investment needed to define a
health related soap market ? Why was the state’s support needed? And what is there to have us
belief that an equal investment in locally manufactured soaps would not have generated both
health and local employment.
This case study has relevance in the Indian context also for a similar public private partnership
was sought to be launched in Kerala. This state has a rich tradition of soap manufacture and an
alert public raised such a debate on it that it was shelved. There are moves to revive this
campaign with local soaps.
We need to explore whether these liberal grants of drugs to major international health campaigns
by leading MNCs is a variant of this strategy. Thus if Smith Kline and Beecham decided to
supply all the drugs needed for the national campaign against filariasis free - it is also managing
to put out of business a number of competitiors who are local producers who can produce these
drugs at rates that they could hardly have matched. Yet these small companies cannot diversify
into newer products so fast as a MNC and if meanwhile the small are run out of the marker by
free drugs then the future market of the transnational is secured against such competition. So is
this just a form of dumping ? We do not know whether such a contention can be sustained.
However different presentations of the issue never raised this dimension to discussion or scrutiny.
So much for the free market.
Does Private Sector partnership improve innovation?
Again there is no reason to believe this. A very small part of R&D private budget goes into new
drugs. Choice of research is governed largely by profitability- Priorities for the poor and tropical
diseases get little if no inputs. Often all the basic research on disease mechanisms and even the
discovery of the active molecule is done in state supported university laboratories -with only the
commercialisation being done by the manufacturer.
Even in clinical methods there is no evidence to say that the private sector is more
Then what really drives the move to public private partnerships:
First and foremost the most important fuel is the very poor state of the public health system.
Not only does it have a lack of investment and a lack of manpower, even where these are
adequate the system is so dysfunctional that it is easy to conclude that there is a problem with
any public system as such. The problem if image is further compounded by the public sector
constantly needing to attract more funds and justify its growth by showing that “ things are
bad and if not... a crisis would result”. In contrast private sector justifies its growth and
attracts investments by proclaiming success irrespective of the real situation. Individuals
blame private sector failures on individual companies/owners whereas the failure of any
faciltity is blamed on the public sector system as a whole -on policy.
But the truth is that except for a top 0.1 % who can afford corporate private care, on the rest of the
private care sector - the jury is still out - even on customer satisfaction. Currently only 22% of all
health care expenditure is borne by the state in India as against an OECD average of over 75% .
Even this OECD average excluding US is much higher- almost 90%. US figures of 44% are
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18
17
considered low. Most developing countries have higher contribution from private sector and it is
consistently less than the figures for the developed world.
• In this context - the first goal should be to strengthen the public sector and regulate the
private sector rather than encourage further an already overgrown and almost completely
unregulated private sector.
The case of State - Civil society partnerships:
One recent trend under the umbrella of the term public private partnerships is the contracting out
of urban health care directed at poor areas and primary health care in remote rural area to NGOs.
Both in Andhra Pradesh and in Assam this has been tried out in a major way.
We already noted that these are not private in the sense of being either corporate or profit driven.
We also note that most of them at least in the start up phase are driven by a notion of service and
altruism. Even if for all the employees and even much of their managements it is primarily also
an employment opportunities at a time of considerable stagnation in employment it still retains a
high degree of service -mindedness largely as they are not professional and share the lay persons
viewpoint of health and disease. Since hiring on such contract terms has less commitments and
less expenditure for the state and since many, especially young women, become available for the
low wages that these jobs offer it seems a win win situation all around.
The catch in it is the issue of governance. The very same reasons why the public sector fared so
poorly rise their head again in the entire process of selecting, costing, monitoring and paying for
the NGOs. Over time except for a very few who are good and adept, most of them would either
get corrupted or drop out, till eventually they have as bad a reputation as the public system, and
become as bureaucratic and corrupt. One hears frequently of how NGOs are a fraud and of how
they are corrupt, just as frequently a sone hears of corruption and sloth in the public employee.
Both charges are right in part and grossly inadequate as they fail to see the relationship with
governance.
In third world contexts ruling sections often see the public exchequer as a source of revenue to
sustain and build their political and personal strengths. A Marcos or an Idi Amin is only an
extreme variant of a general situation where it has almost become acceptable for a politician to
dip into the treasury - if it is done for the party. The economically powerful do not support (or
cannot) the politicians campaigns unlike what happens in the advanced countries. Looting the
public exchequer becomes then a form of primitive accumulation of capital in the developing
context.The public health system too is beset with corruption at its highest levels- and this can be
sustained only is the entire purposes of administration are made to extract this sum out - thereby
pervading the system from top to bottom with a parallel and perverse system of values.
When because of this the public system is discredited- largely attributed to the recalcitrance of the
public sector employee - this section moves on the new idiom - PPP carrying along with it the
same problems of governance. To no ones surprise then PPP fairs no better - and if the public
health system was dysfunctional the PPPs become a series of scams. And Public civil society
cooperation is also pushed by these same issues of governance -slowly in the same direction. One
cannot therefore look to these strategies as ever being able to get around the central issues of
governance and the oppressive and exploitative nature of current ruling systems.
How (hen does one build up resistance to this retreat of the state?
First and foremost is developing awareness amongst the people, especially the poorest that health
is a fundamental right and health care services is an entitlement to secure which one mobilize for
collective action.
3
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48
Information on Global Public Private Initiatives in Health: GPPIs
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1. Introduction and
highlights
The health situation of poor people in low
and lower middle income countries is a matter
of great concern. Millions of people do not
have access to sufficient food, safe drinking
water, adequate housing and health care.
Large numbers of people die every day of
preventable and treatable illnesses. As a
response to the present health crisis, UN
health related agencies are increasingly
appealing to companies and rich individuals
to provide funds and other resources for
This booklet has been compiled within the
framework of the Wemos project ‘Health and
the Private Sector’. Wemos is of the opinion
that an integrated approach to health is
needed to ensure the fulfilment of the right
to health for all. This implies, amongst other
things, the need for strengthening of health
systems that guarantee accessible health
services for all and are based upon the needs
of the people they are meant to serve.
the improvement of people’s health in poor
That large companies and rich individuals are
willing to take responsibility for fighting the
countries. Together with UN bodies such as
ill-health of millions of people is a positive
the World Health Organisation (WHO) and
development. The question is whether the
governments, they are engaging in a growing
present GPPIs are an effective way to improve
people’s health.
number of so-called Global Public Private
Initiatives or Partnerships (GPPIs).
Partnerships between the public and the
private sector are not new; its international
dimension has, however, created a relatively
new phenomenon.
At this moment, there are around 80 GPPIs
working in the field of health, and new partner
As part of this project, a series of case studies
is being carried out by Southern partner
organisations in order to shed light on the
performance of some GPPIs programmes at
country level and the consequences of these
programmes for local health systems.
In Uganda, Tanzania and Zambia, Roll Back
ships are launched regularly. In Tanzania,
Malaria is investigated. In South Africa, one
28 partnerships are implementing activities.
of Wemos’ partners is looking at Stop TB.
In Uganda 25 partnerships are active, in Mali
A Kenyan partner organisation is doing re
24 and Zambia, Mozambique and Senegal
search on the Global Alliance to Eliminate
count 23 global partnerships. Most of them
focus on the development of a product
Lymphatic Filariasis and in India the Global
Polio Eradication Initiative and the Global
(e.g. development of a vaccine) or the
Alliance to Eliminate Lymphatic Filariasis are
improvement of access to health products
being investigated. The results of these studies
(e.g. access to medicines for leprosy). 13 of
will be available in the summer of 2004.
these partnerships are focussed on different
aspects of malaria, 12 on HIV/AIDS and 9 on
tuberculosis.
This booklet is based on a study carried out
in 2003 on behalf of Wemos. 79 GPPIs were
studied, most involving the WHO.
The researchers used information available
on the websites of GPPIs themselves, their
partners, non-governmental institutions
(NGOs) and independent reports. Out of the
79,10 were selected to be studied in more
detail, looking at aspects such as their objec
tives, which public and private institutions
are involved and how decisions are made
and implemented.
e0n Ondlia, 40 percent of She population
Boyes heDow the poverty line. We welcome
new partnerships, hut they will have to
work. They have to work for the people.’
Mr. Poddar, West Bengal Voluntary Health
Association, India
Good intentions with side-effects, drawing on
the results of the research, is aimed at giving
an idea of what exactly partnerships are and
iwhat their side-effects might be. The booklet
(includes a close look at one of the largest and
pnost influential GPPI, the Global Alliance for
v/accines and Immunisation (GAVI). Also, an
p,,verview is given of the 79 GPPIs that were
5ttudied, and 10 partnerships are described in
.jOre detail.
VACCINE
2. GPPIs
What are they?
Objectives, strategies and activities
Looking at the objectives, activities and
strategies of 79 GPPIs reveals an overriding
emphasis on a specific disease, linked to the
access to, or development of a specific drug
or vaccine. Typical too will be a clearly
expressed target like ‘50 percent reduction’
or ‘eradication’. Diseases commonly targeted
are malaria, tuberculosis (TB), H1V/AIDS and
other infectious diseases. Almost half concern
health requires all sectors to pull together,
including business. In this context, the WHO
developed ‘Guidelines on working with the
private sector’. These guidelines were inten
ded primarily to help WHO staff interact
appropriately with commercial enterprises
and avoid conflict of interest.
The World Bank is also an important multi
lateral player, mostly acting as a custodian of
development or access to drugs, vaccines and
funds managed by a GPPI. For governments
other health products. By contrast little more
than one in ten states strengthening health
of low income countries, GPPIs represent
another source of financial and technical
services as one of their objectives.
support for their activities in health. Health
budgets often amount to less than 13 US
Who are they? Main participants
dollar per person per year (1) and many
governments argue that any outside funding
Public
WHO and UNICEF are the principal inter
national governmental or multilateral
organisations, having a stake in respectively
62 percent and 33 percent of all global
partnerships in health. Typically the WHO
takes responsibility for high-level technical
decisions while UNICEF plays a more ope
rational role driven by the number of
vaccine-related GPPIs and the high burden
of disease borne by children. GPPIs are seen
as an important way for UN organisations
is welcome to fight the present health crisis.
The WHO Commission on Macro-economics
and Health estimates that at least 30 to 40
US dollar per person per year is needed to
cover essential interventions, including those
needed to fight the AIDS pandemic.
Private
The most common philanthropic foundations
are the Bill and Melinda Gates Foundation
and the Rockefeller Foundation, with Gates
to increase access to funding. UN secretary
by far the most involved. The pharmaceutical
general Kofi Annan told the World Economic
companies GlaxoSmithKline (GSK) and Merck
Forum in 1999 that prosperity could not be
are the most common of a concentrated group
achieved without partnerships involving the
business community. The World Health
of six commercial pharmaceutical companies.
Organisation’s ex-director Gro Harlem Brundt-
socially responsible and purely economic.
land argued too that the complexity of today’s
Transnational companies have become so
Private capital’s involvement may be both
WlrH© and HJJnicef have a stake in respectively
32 percent and 33 percent of all global
partnerships in health
large and powerful that it is almost inevitable
they will touch on larger social questions
And How?
Organisational arrangements
such as AIDS/HIV and malaria. Shareholders
will demand an increased sense of social
responsibility and businesses would rather
not operate in the global insecurity posed by
The research of ten GPPIs showed most were
organised through an international board that
usually meets infrequently to consider large
funding allocations, strategic direction and
the threat of diseases such as HIV/AIDS. But
unlike previous “donations", “partnerships”
changes in objectives. Typically the GPPI
boards take funding decisions in response to
proposals from recipient countries. These
have been made according to a set framework
previously established by the donors.
suggest a degree of leverage. All partners,
including private capital, have a say in
decisions and have interests, which should
be addressed. And companies have much
to gain. GPPIs can carve out new markets for
the future; vaccines can be introduced to the
business potential of the developing world.
GPPIs can also boost the public image of a
company, becoming a part of its whole
corporate planning.
NGOs are typically being involved in GPPIs
because of their presence in a particular target country. Medecins Sans Frontieres (MSF)
and the Programme for Appropriate Techno
logy in Health (PATH) are the most common,
playing a role in GPPIs they themselves have
launched. Other participants include deve
loped country government departments such
as USAID and academic institutions such as
the London School of Hygiene and Tropical
Medicine.
Other research on GPPIs governing structure
reveals that certain groups are systematically
under-represented in governing bodies of
GPPIs, particularly Southern governments
and civil society organisations (2). The Global
Alliance to Improve Nutrition (GAIN) is an
exception in this respect. GAIN gives poor
countries a 40 percent stake, while the rest
including private industry, private foundations,
NGOs, bi-and multi-lateral agencies such as the
UN and scientific agencies have 10 percent
each. However, the voting rights structure
does not provide the full picture of the power
structure within GPPIs. While drug companies
may not have a majority of votes on a GPPI
board, they exercise huge influence over deci
sion making, because without their continued
and voluntary donations many GPPIs would
simply collapse.
GPPIs are almost always based in Western
Which information is available?
countries: their headquarters are close to
The amount of information published on the
those of the private company or multilateral
GPPI’s websites depends partly on the size
agency that launched them. Of the 79 GPPIs
and public profile of the GPPI. For example,
studied, only four had a headquarter based in
the collaboration between Japanese
a recipient country. Due to the costs of travel,
pharmaceuticals, the ministry of health and
the WHO’s malaria venture, a relatively small
some authors suggest that partners or poten
tial partners from poor countries may be at
a disadvantage to participate in decision
making processes.
How much money is involved?
Though it is quite difficult to obtain information
on the exact budget of GPPIs, it is possible to
make a rough estimate using different sources.
GPPI, appeared to be hardly documented on
the web.
By contrast the Global Alliance for Vaccines
and Immunisation (GAVI) publishes extensive
information on its website including its objec
tives, a progress report, and the names and
roles of board and secretariat members.
For example, the Global Polio Eradication
The researchers conclude that GPPIs rarely
publish much information on finances and
Initiative has spent 2 billion US dollar since
progress towards their aims. What they do
1985. Her budget for 2002 until 2007 is about
publish is an overriding focus on easy to
1 billion US dollar. The Global Alliance for the
measure targets, such as the number of
Elimination of Lymphatic Filariasis has an
persons covered by immunisation or receiving
annual budget of about 100 million US dollar.
a specific treatment.
Roll Back Malaria could spend 165 million
US dollar in 2002. The Stop TB partnership
has a budget of around 600 million US dollar
per year. The Global Alliance for Vaccines and
Immunisation has had about 1,14 billion US
dollar to spend since 2001. In comparison:
the total budget of the WHO for 2004-2005
is 2,8 billion US dollar.
GPPIs are almost always
based in Western countries
3. Good intentions
with side-effects
This study and earlier studies on GPPIs show
that some have had positive outcomes. They
deliver funding, draw attention to largely
unknown health threats such as river blind
ness, and some have been very successful
in achieving their goals. For example, one of
the earliest GPPIs, the Global Polio
Eradication Initiative has made great gains
in eradicating the disease in almost every
region of the world.
But there are risks too. The main risks asso
ciated with GPPIs concern their sustainability,
invested in by the country’s health system
and requiring a commitment over many
years, would collapse.
Dependency on new, sometimes more
expensive drugs or vaccines, also affects
the sustainability of the partnership. In the
case of the Global Alliance for Vaccines and
Immunisation, Ghana has accepted a more
expensive vaccine (pentavalent) because the
cheaper quadravalent version was not availa
ble at that moment. If the GPPI would stop
governance and accountability.
and the government would have to continue
the programme, they have to spend a large
part of their budget on these vaccines and
Sustainability
other health priorities could suffer.
In discussions about the increasing importance
of GPPIs, questions are often raised about
Another example is the Accelerating Access
the sustainability of the funding and of the
Initiative (AAI), which aims to reduce the prices
health improvements. GPPIs rarely include
of HIV/AIDS medicines. According to Act Up
explicit financial commitments of the com
Paris, the pharmaceutical companies working
mercial sector beyond five years. Merck’s
in the AAI let countries sign confidential
donation of the drug Mectizan, in the frame
work of the Mectizan Donation Programme,
agreements that aim to prevent competition
with generic HIV/AIDS medicines (3). The
is remarkable for explicitly stating that the
absence of generic medicines makes coun
donation is indefinite. With other GPPIs, this
tries fully dependent on the willingness of
is not the case. If, for example, in the frame
international pharmaceutical companies to
offer their medicines at a lower price. If these
work of the Global Alliance for the Elimination
company GSK decided to withdraw its com
companies decide to increase their prices,
governments have no alternative and are
mitment to donate the drug albendazole to
forced to purchase these more expensive
a specific country, then the initiative would
patented medicines.
of Lymphatic Filariasis, the pharmaceutical
stop. Poor countries cannot insist on the
support of GSK. A commitment to donate
Finally, the number of GPPIs operating in one
is not enshrined within any governance
single country and the number of these GPPI
documents available. Without it the GPPI,
programmes directed to the same health
problem might pose questions about sus
tainability and efficiency.
Especially because each partnership works
with a different perspective and with a diffe
rent approach, but makes use of the same
health system to implement their plans.
When these programmes are not well coordi
nated, it might lead to overuse of the already
weak health system. Then the situation could
more than 200 partners), this does not gua
rantee democratic decision making.
So far, research concludes a gross under
representation of stakeholders from poor
countries and a lack of specific criteria for
defining the “rights, privileges and obligations
associated with partners status”(4). Most
decision-making power sits in the hands of
arise that a country does have access to the
multilateral institutions and the commercial
sector. By contrast, poor countries’ govern
medicines it needs, but lacks the infrastruc
ture to deliver it to the patients.
and design of GPPIs.
Governance and accountability
Another ‘hot item’ is the way in which GPPIs
are governed. This whole question of “gover
nance” is attracting attention as it is breaking
new ground. For the first time on a global
scale, public, commercial and civil society
are being brought together through partner
ships to achieve shared health goals. Related
to this is the issue of transparency and in
formation about the operational structure,
ments have less of a voice in the formation
Some researches state that accountability
in partnerships is complex and contested.
Complex, because it involves the accounta
bility of the executive staff to the governing
body of the GPPI, of the governing body to
its stakeholders, and of the partners of the
GPPI to the GPPI itself. Contested, because
opinions differ whether these partnerships
need to be accountable only to the donors
and main stakeholders or need to be accoun
decision making processes and accountability
mechanisms for GPPIs.
table to any social group affected or involved
Though a sufficiently wide group of stake
making mechanisms makes these partner
holders is normally in place to make decisions
ships very low accountable to populations
to whom they are directed.
(for example, the Stop TB partnership counts
.
in the GPPIs' programmes. The lack of repre
sentation of the target population in decision
The main risks associated with GPPIs
concern their sustainability, governance
and accountability
4. Am example: The GGohai Alliance
for Vaccines anol Immunisation (GAVOJ
GAVI was launched in January 2000 at the World Economic Forum in response to international
concern over a decade of declining childhood immunisation rates. This decline had had a devasta
ting effect on child mortality. GAVI brought together an alliance of national governments, the WHO,
UNICEF, the World Bank, the Bill and Melinda Gates Foundation and industry, represented by the
International Federation of Pharmaceutical Manufacturers’ Associations. It aimed to provide a
new mechanism for coordinating partner organisations’ efforts to revitalise international support
for immunisation.
Turning bach the tide on
childhood disease
New initiative, new methods,
new money
In 1974 the World Health Assembly had laun
GAVI is significant as one of the first of the new
ched The Expanded Programme on Immuni
GPPIs launched in the last five years. It is also
one of the biggest and is mostly funded by
sation (EPI) which achieved real successes.
By 1980 UNICEF could report that immuni
sation rates against the six major childhood
the largest private donor, the Bill and Melinda
diseases, diphtheria, tetanus, whooping
cough, polio, measles and tuberculosis, had
million. There was also support from national
leapt from 5 percent to 80 percent. It then
(USS 159 million over three years), the
stalled and began to fail. This was caused
by a variety of inter-related reasons including
Netherlands (USS 85 million over five years),
to Ireland (USS 0.5 for one year). While a
war, HIV/AIDS, donor fatigue and a change
of leadership al the WHO. By 2000, global
board sets its overall objectives, structures
coverage on immunisation had dropped to
75 percent. In 19, mostly African countries,
immunisation rates against diphtheria, teta
Gates Foundation, that committed USS 750
governments, ranging from the United States
and recommendations for funding, a separate
and mutually interdependent Vaccine Fund
has the final say on applications to the GAVI.
A stated additional aim of this Fund is to
nus and polio had dropped below 50 percent.
Yet as early as September 2003, GAVI could
“demonstrate to vaccine manufacturers that a
claim that 30 million of the world’s poorest
children had benefited in just three years.
vaccines”.
250 million US dollar had been distributed
among 60 countries and an estimated
“300,000 deaths had been prevented” (5).
developing country market exists for newer
Unlike many GPPIs, it spelt out clear objectives.
These include expanding the use of existing
under-utilised vaccines in 74 countries, sup
porting the development of new vaccines,
improving access to sustainable immunisa
tion services, expanding the use of existing
cost-effective vaccines and promoting the
delivery of other appropriate interventions at
immunisation centres. It also spelt out clear
goals. These included that 80 percent of poor
As early as September
SOOS @AMH gi&ujiOgII GBaornn
SOOsOOO dearths
beemi prevented
countries would have at least 80 percent rou
tine immunisation coverage by 2005. Also
specific targets were added for hepatitis B
(hep B) and haemophilus influenzae type b
(Hib) vaccination.
GAVI is significant sis one of the
first of the new GPlPUs launched
in the last five years
Return to immunisation
A report by UK-based NGO Save the Children
One example is the decision to provide
looked in 2001 at how GAVI actually worked
on the ground in four countries: Ghana,
auto-disposable syringes for all vaccines in
Mozambique, Tanzania and Lesotho.
new vaccines. This helped allay fears that
In general they welcomed the renewed focus
re-usable syringes could put their children
at risk from HIV.
on immunisation, the strengthening of coun
the expanded programme and not just for
tries’ immunisation coordinating committees,
the introduction of safe injections and equip
ment for hepatitis B vaccine, and the provision
However, critical remarks have been made
about the limited attention paid to strengthe
of technical support. Countries particularly
ning the infrastructure needed to vaccinate
welcomed the freedom GAVI allowed, in
children. Health Action International Europe,
contrast to other donors, in the way money
for example, noted that among the first
was spent on supporting health systems.
awards in 2000/2001 only 10 percent were for
strengthening immunisation services while 90
percent were for developing and introducing
Welcome too was the chance GAVI offered to
provide hepatitis B vaccine, which countries had
previously wanted but found too expensive.
new vaccines, mainly hep B (6). A good sign
is that in the proposals for 2002 this percen
There was also evidence that GAVI was get
ting feedback and learning from individual
budget was awarded to strengthening of
country’s experience. The “evolutionary”
immunisation delivery systems (7).
aspect of GAVI has been praised.
14
tage had increased: 28 percent of the total
Risks
All the benefits of the GAVI programme could
be jeopardised by its over dependence on
The Save the Children study raises serious
concerns about sustaining funding for the
the inadequate systems currently operating.
GAVI after its initial lifespan of five years.
A notable finding, it concludes, is a lack of
discussion and co-ordination about future
Because it is incorporated into routine immu
nisation services it may suffer from the same
chronic under-investment. Examples from the
Save the Children report speak of broken
financing. It sees little evidence that indivi
fridges and thermostats, a lack of fuel for
dual agencies will meet future costs especially,
for example, where countries have opted for
transport, staff shortages and inadequate
facilities for disposing of syringes. Much of
cost of Ghana’s expanded programme on
rural Mozambique, for example, has no ade
quate cold chain equipment to store the vac
This will treble with the introduction of the
expensive combination vaccines. The current
immunisation is SUS 3.7 million a year.
cines. With these crippling problems, efforts
pentavalent vaccine, which is part of the
to extend immunisation coverage and ensure
supervision and monitoring, an important
GAVI programme in Ghana. If GAVI would
decide to stop its activities in Ghana, it may
aim of GAVI, are threatened. GAVI’s system
be politically damaging for the government to
support funds alone cannot hope to redress
withdraw from costly programmes such as the
such structural weaknesses and attention
pentavalent vaccine programme. As a result,
other greater health priorities could suffer.
should be paid to more sustainable health
system improvements in order to achieve the
GAVI objectives.
5. Concluding remarks
In this booklet, a brief introduction to GPPIs
o
Participation - Is the strategy and approach
in health has been provided. It is too early
of the GPPI the result of consultation
to have in-depth insight into the effects of
with the recipient country? Does it reflect
GPPIs. More research on the performance
of GPPIs at country level is needed in order
their main priorities?
o
Sustainability - Does the GPPI strengthen
to decide whether the present GPPIs are an
local health system structures, enabling
effective way to improve people’s health in
poor countries and if not, what should be
people to help themselves in the future?
done to improve their effectiveness. The
frame? Does the GPPI give attention to
prevention and the cause of the targeted
Does the GPPI look beyond its set time
Wemos’ case studies, available this summer,
will provide more information.
disease?
o
In the mean time, based on the available
information, Wemos proposes a series of
clear criteria that can be used to assess
whether GPPIs are an effective instrument
Accountability - Is the GPPI accountable
to the public? Is the decision making
process transparent? Are the WHO guide
lines on interaction with the private sector
being followed?
in improving people’s health:
When these criteria are met, GPPIs will be
able to make a contribution to sustainable
improvements in people’s health. Without
attention for participation, sustainability
and accountability the good intentions of
all partners involved may be jeopardised.
GPPIs might then at best make a contribution
to fighting an illness for a set period of time,
but will not lead to the sustainable health
improvements, that GPPIs are created for.
It is too early to have in-depth
insight into the effects of GPPIs
6. Annexes
Annex i: List of the analysed GPPIs, with their targeted diseases/risk factors
Full Name
Disease / Risk Factor
Global Alliance to Eliminate Leprosy (GAEL)
Leprosy
Accelerating Access Initiative to HIV Care (AAI)
HIV/AIDS
Global Polio Eradication Initiative (GPEI)
Polio
Int'l. Partnership Against Aids in Africa (IPAAA)
HIV/AIDS
The Global Fund to Fight AIDS,
HIV/AIDS, Malaria, Tuberculosis (TB)
Tuberculosis and Malaria (The Global Fund)
Global Alliance for the Elimination of Lymphatic
Lymphatic Filariasis (LF)
Filariasis (GAELF)
Global Alliance for Improved Nutrition (GAIN)
Micronutrient deficiency
Global Alliance for Vaccines and Immunisation (GAVI)
Vaccine-preventable diseases of the poor
Roll Back Malaria Global Partnership (RBM)
Malaria
Stop TB Partnership (Stop TB)
Tuberculosis (TB)
WHO-Pharmaceutical Industry Associations-NGO
Counterfeit and substandard drugs
Anti-Counterfeit Drug Initiatives
African programme for Onchocerciasis Control (APOC)
Onchocerciasis (river blindness)
Meningitis Vaccine Project at WHO/PATH (MVP)
Meningitis
WHO programme to Eliminate Sleeping Sickness (WPESS)
Human African trypanosomiasis
Japanese Pharmaceutical, Ministry of Health,
Malaria
WHO Malaria Drug Partnership (JPMW)
Mectizan Donation programme (Mectizan)
Lymphatic Filariasis (LF). Onchocerciasis
(river blindness)
Partnership for the use of social sciences in malaria control
Malaria
Global Elimination ofTrachoma (GET 2020)
Blindness, Trachoma
WHO/Novartis Coartem®
Malaria
Action TB programme
Tuberculosis (TB)
African Comprehensive HIV/AIDS Partnerships (ACHAP)
HIV/AIDS
Alliance for Microbicide Development (AMO)
HIV/AIDS, Sexually transmitted infections
Concept Foundation
Reproductive health
CONRAD
Reproductive health
Corporate Council on Africa (CCA)
HIV/AIDS
Diflucan Partnership programme
HIV/AIDS
Foundation for Innovative New Diagnostics (FIND)
Diagnostics, Tuberculosis (TB)
Global Alliance for TB Drug Development (TB Alliance)
Tuberculosis (TB)
Global Business Coalition on HIV & AIDS (GBC)
HIV/AIDS
Global Guinea Worm Eradication programme (GWEP)
Guinea worm (dracunculiasis) disease
Global Microbicide Project (GMP)
Sexually transmitted infections
Global Public-Private Partnership for Hand Washing with Soap (GPHW) Communicable diseases
Global Reporting Initiative (GRI)
HIV/AIDS
Hope for African Children Initiative (HACI)
HIV/AIDS
Intercompany Collaboration for AIDS Drug Development (ICCADD)
HIV/AIDS
International AIDS Vaccine Initiative (IAVI)
HIV/AIDS
International Partnership for Microbicides (IPM)
Sexually transmitted infections
International programme on Chemical Safety (IPCS)
Chemical safety information
Lilly Multi-Drug Resistant Tuberculosis Partnership
Tuberculosis (TB)
Maternal and Neonatal Tetanus, Global Elimination of (MNT)
Tetanus, maternal and neonatal
Microbicides Development programme (MDP)
HIV/AIDS, Sexually transmitted infections
MTCT-Plus Initiative
HIV/AIDS
Safe Injection Global Network (SIGN)
Injection safety, syringes
Secure the Future
HIV/AIDS, Sexually transmitted infections
Sequella Global Tuberculosis Foundation (SGTBF)
Tuberculosis (TB)
Step Forward programme
HIV/AIDS
Strategies for Enhancing Access to Medicines (SEAM)
Diseases of the poor
at Management Sciences for Health (MSH)
Tuberculosis Diagnostics Initiative (TBDI)
Tuberculosis (TB)
UNFPA Contraceptives Access Project (UNFPA/lndustry)
Reproductive health
(Profile in Progress)
Viramune® Donation programme (VDP)
HIV/AIDS
Alliance for Health Policy and Systems Research (AHPSR)
Health policies and health systems
Artesunate Suppository for Emergency Treatment of Severe Malaria
Malaria
Children's Vaccine programme at PATH (CVP at PATH)
Vaccine-preventable diseases of the poor
Consortium for Industrial Collaboration in
Sexually transmitted infections
Contraceptive Research (CICCR)
Dengue Vaccine Project (DVP)
Dengue
Drugs for Neglected Diseases Initiative (DNDi)
Chagas, Leishmaniasis,
European Malaria Vaccine Initiative (EMVI)
Malaria
Gates Foundation/U. of North Carolina Partnership
Leishmaniasis, Human African trypanosomiasis
Human African trypanosomiasis
for the Development of New Drugs (GFUNC)
Health InterNetwork (HIN)
Digital divide
Hookworm Vaccine Initiative (HVI)
Hookworm
Infectious Disease Research Institute (IDRI)
Chagas, Leishmaniasis, Leprosy, Malaria,
Tuberculosis (TB)
Institute for OneWorld Health (IOWH)
Parasitic and other neglected infectious diseases
Lapdap Antimalarial Product Development (LAPDAP)
Malaria
Lassa Fever Initiative (LFI)
Lassa fever
Malaria Vaccine Initiative (MVI)
Malaria
Medecins Sans Frontieres Drugs for Neglected
Neglected diseases
Diseases Working Group (MSF DND)
18
Medicines for Malaria Venture (MMV)
Malaria
International Trachoma Initiative (ITI)
Blindness, Trachoma
Int'l. Conf, on Harmonisation of Technical Reqs for
Registration of Pharmaceuticals Human Use (ICH)
Harmonisation of drug applications
Micronutrient Initiative (Ml)
Micronutrient deficiency
Multilateral Initiative on Malaria (MIM)
Malaria
NetMark PLUS, a Regional Partnership for Sustainable
Malaria
Malaria Prevention
Pediatric Dengue Vaccine Initiative (PDVI)
Dengue
Pharmaceutical Security Institute (PSI)
Counterfeit and substandard drugs
Single Nucleotide Polymorphisms Consortium Ltd (SNP)
All human diseases and medical conditions
Vaccine Fund (VF)
Vaccine-preventable diseases of the poor
Vaccine Vial Monitors (VVMs), Development of
Vaccine vial monitors
Vision 2020
Blindness, Cataract, Onchocerciasis (river blindness),
Trachoma
Vitamin A Global Initiative (VITA)
Vitamin A deficiency
Children's Vaccine Initiative (CVI) - HISTORICAL*
Vaccine-preventable diseases of the poor
Malarone Donation programme - HISTORICAL
Malaria
Meningitis C Vaccine Development and Supply in UK • HISTORICAL Meningitis
Norplant, Development of - HISTORICAL
Reproductive health
Onchocerciasis Control programme in West Africa (OCP) - HISTORICAL Onchocerciasis (river blindness)
Oral Rehydration Salts (ORS) Commercialisation in Bolivia - HISTORICAL Diarrhea dehydration
Praziquantel Manufacturing Project ■ HISTORICAL
Schistosomiasis
Syringes - Autodestruct Development - HISTORICAL
Injection safety, syringes
HISTORICAL means the GPPI has ended.
Annex 2: Overview of 10 GPPIs
Name
Accelerating Access Initiative to HIV Care (AAI)
Disease or risk factor focus
HIV/AIDS
Brief description
Announced in May 2000, the initiative involves a dialogue between the UN and
the pharmaceutical industry with the intention of making HIV/AIDS medicines
and diagnostic equipment more available and affordable in the hardest hit
regions of the world. It is a cooperative endeavour involving five UN organisa
tions and six pharmaceutical companies. AAI is involved in negotiating deeply
discounted drug prices for countries that can provide proof they have the health
services to handle the complicated HIV/AIDS medicines. Facilitated by UNAIDS,
governments negotiate with the pharmaceutical companies about ARV- prices.
Objectives
0 To increase access to HIV/AIDS care, treatment and support in resource-poor
settings
0 To improve access to care, including treatments for opportunistic infections
and antiretroviral therapy, in the hardest-hit regions of the world
Approach
Main participants
Improvement of access to health products
Public sector: WHO, World Bank, UNICEF, UNAIDS, etc.
Private sector: GlaxoSmithKline, Merck, Bristol-Myers Squibb, Abbott,
Boehringer Ingelheim, Hoffman La Roche, etc.
Target countries
Bahamas, Barbados, Benin, Botswana, Burkina Faso, Burundi, Cameroon,
Chad, Chile, Congo, Cote d'Ivoire, Democratic Republic of the Congo, Gabon,
Honduras, Jamaica, Mali, Malawi, Marocco, Romania, Rwanda, Senegal,
Trinidad and Tobago, Uganda, South Africa
Website
www.unaids.org
Name
Global Alliance for Elimination of Leprosy (GAEL)
Disease or risk factor focus
Leprosy
Brief description
The Global Alliance was initiated by WHO in 1999 to ensure that a common
strategy based on experience of past leprosy elimination efforts was adopted,
intensively implemented and effectively monitored. GAEL is a partnership dedi
cated to ensuring that all leprosy patients, wherever they may live, and however
poor, have free and equal access to the most modern of treatment available.
Multi-drug therapy (MDT) has been made available free of charge from WHO,
thanks to a donation by Novartis which make the drugs and financial support by
the Nippon and Sasakawa Foundations. MDT provides a simple yet highly effec
tive cure for all types of leprosy in just six to twelve months. The goal of GAEL is
to eliminate leprosy as a public health problem from every country by the year
2005 and to detect and cure all the remaining leprosy cases currently estimates
at over 2.5 million. GAEL includes WHO, governments of endemic countries, the
International Federation of Anti-Leprosy Associations, NGOs, DANIDA, the World
Bank, the Nippon Foundation and the Sasakawa Memorial Health Foundation.
Objectives
To detect and cure all remaining leprosy cases (estimated at 2.8 million), in
order to eliminate it from every country by 2005 (elimination as attaining a
level of prevalence below one case per 10 000 population)
Approach
Improvement of access to health products
Main participants
Public sector: WHO, World Bank, Ministries of Health in target countries,
DANIDA. etc.
Private for-profit sector:, GlaxoSmithKline, Merck, Novartis, Binax, etc.
Private not-for-profit sector: Bill and Melinda Gates Foundation, Sasakawa
Memorial Health Foundation, Nippon Foundation, International Leprosy
Association (ILA), International Federation of Anti-Leprosy Associations (ILEP),
The Leprosy Mission (TLM), etc.
Target countries
Angola, Brazil. Guinea, India, Madagascar, Mozambique, Myanmar, Nepal
Website
www.who.int/lep
Name
Disease or risk factor focus
Global Alliance for the Elimination of Lymphatic Filariasis (GAELF)
Lymphatic Filariasis (also known as elephantiasis)
Onchocerciasis (river blindness) in countries where the diseases co-exist
Brief description
GAELF exists to eliminate lymphatic filarisasis worldwide. LF is a dehabilitating
condition caused by two types of parasite, spread by mosquitoes, that occupy
the lymph nodes and which in conjunction with secondary bacterial & fungal
infections may cause swelling of the limbs and genitals causing social stigma
and restricting the ability to work and travel. In 1995 the WHR identified LF as
the second leading cause of disability in the world. WHO is the secretariat for
this partnership forum for the exchange of ideas & coordination of activities;
with membership open to all interested parties. GAELF members include
governments of endemic countries, plus 39 organisations from public and priva
te sectors, academia, government bodies & NGOs. It was founded in May 2000.
Its cornerstones are the WHO which directs and coordinates activities, the
Gates Foundation, which donated S2om in 2000, and GSK which has made a
$t.6bn commitment to supply drugs until the disease is eliminated.
Objectives
0 To eradicate LF by 2020
0 To interrupt transmission of infection
0 To alleviate and prevent the suffering and disability caused by the disease
identified in more than 20m people worldwide
Approach
Improvement of access to health products
Main participants
Public sector: WHO, UNICEF, World Bank, US Centres for Disease Control &
Prevention (CDC), Ministries of Health in target countries, USAID, UK
Department for International Development (DFID), government of Belgium,
Spain, Italy, Japan, Netherlands, etc.
Private for-profit sector: GlaxoSmithKline. Merck, Binax, etc.
Private not-for-profit sector: Bill and Melinda Gates Foundation, Carter Center,
Arab Fund for Economic and Social Development, Caribbean Epidemiological
Centre (CAREC), Secretariat for the Pacific Community, South East Asian
Ministers of Education Organisation (SEAMED), etc.
Target countries
79 countries
Website
www.filariasis.org
t
Name
Global Polio Eradication Initiative (GPEI)
Disease or risk factor focus
Poliomyelitis
Brief description
A multi-partner, informal coalition supporting the WHO goal and strategies for
eradication of poliomyelitis. Partners include others UN Agencies, other NGOs,
national development assistance and technical agencies. The spearheading
partners are the WHO. Rotary International, The CDC and UNICEF. Industry has
donated polio vaccine and funds to support surveillance.
Objectives
o To interrupt transmission of the wild poliovirus globally and certify all WHO
regions polio-free by the end of 2005
0 To achieve global certification of polio eradication, including containment of
the wild poliovirus, and the development of a post-eradication immunisation
policy
0 To contribute to health systems development by strengthening routine immu
nisation and surveillance for communicable diseases
Approach
Improvement of access to health products
Main participants
Public sector: WHO, UNICEF, World Bank, US Centres for Disease Control &
Prevention (CDC), USAID, UK Department for International Development (DFID),
Canadian International Development Agency, government of Finland, Germany,
Netherlands, Japan, Italy, Belgium, Denmark, EU, etc.
Private for-profit sector: Aventis Pharmaceuticals, De Beers, Wyeth, Rotary
International, and Vaccine Manufacturers Network, etc.
Private not-for-profit sector: UN Foundation, GAVI, Bill and Melinda Gates
Foundation, Australian International Health Institute, Red Cross, etc.
Target countries
Afghanistan, Angola, Egypt, Ethiopia, India, Niger, Nigeria, Pakistan,
Website
www.polioeradication.org
Somalia, Sudan
Name
Global Alliance to Improve Nutrition (GAIN)
Disease or risk factor focus
Micronutrients deficiencies
Brief description
GAIN was launched in May 2002 during the United Nations General Assemby
Special Session on Children and is a collaboration between the diverse stake
holders: public sector, commercial sector, non-profit sector, bilaterals, multilate
rals & academic institutions, with the emphasis on including public and private
sector partners with the aim of reducing ill-health caused by malnutrition,
especially deficiencies of micronutrients. It has an independent non-profit legal
status. Their focus is on the promotion of food fortification programmes by food
producers in collaboration with the public sector. They also promote nutrition
awareness at strategic and consumer levels. They specifically exclude conside
ration of micronutrient supplements, leaving this to other agencies. Various
activities include policy formulation, setting standards, capacity building, advo
cacy, marketing & operational research. As the alliance is relatively young there
is no sustained period of operation during which performance can be analysed.
C
They recognise that malnutrition is driven by social and economic factors and
therefore target poor communities. GAIN is governed by a Board and administerd
by a Secretariat and was incorporated as a Swiss Foundation in March 2003.
Objectives
0 GAIN is an alliance of public, private and civil society organisations committed
to saving lives and improving health through the elimination of vitamin and
mineral deficiency. This is targeted primarily through facilitating fortification
of commonly available and consumed local foods.
0 By contributing to the reduction of micronutrient deficiencies, GAIN aims to
decrease child and maternal morbidity and mortality, lessen health care costs,
improve productivity, & promote the ability of populations to achieve their
physical and intellectual potential
0 A particular emphasis on children; poor communities; and vitamin A, iodine,
folic acid and iron
Approach
Global coordination mechanism, public advocacy, education and research, regu
lation and quality assurance
Main participants
Public sector: WHO, Unicef, World Bank, US Centres for Disease Control &
Prevention (CDC), UN Food and Agriculture Organisation (FAO), World Food
Programme, USAID, Canadian International Development Agency, government
of Germany, national food fortification associations, etc.
Private for-profit sector: Procter & Gamble. Heinz, Unilever. Roche. International
Life Sciences Institute, Salt Institute, etc.
Private not-for-profit sector: Bill and Melinda Gates Foundation, Helen Keller
International, Program for Appropriate Technology in Health (PATH), SUSTAIN,
Micronutrient Initiative, PAHO, International Union of Nutritional Sciences,
International Food Policy Research Institute, etc.
Target countries
Bolivia, China, Cote d'Ivoire, Dominican Republic, Indonesia, Iran, Jordan,
Kazakhstan, Morocco, Nigeria, Philippines, South Africa, Thailand, Uzbekistan,
Vietnam, Zambia
Website
www.gainhealth.org
________ ______________________________
'.
Name
Global Alliance for Vaccines & Immunisation (GAVI)
Disease or risk factor focus
Vaccine-preventable diseases of the poor
Brief description
GAVI was established in 1999. It partners private and public sector to improve
health and "save children's lives" through the widespread use of vaccines -
full vaccine coverage would save 3m lives a year. International organisations,
governments, vaccine industry, research institutions, and foundations have
formed a partnership to develop and push GAVI objectives. They work with the
governments of target countries which are listed below and must have a GNP of
less than $1000 pppa. GAVI directs the Vaccine Fund to "fuel poorer countries’
long-term efforts to provide children with basic access to life saving vaccines".
At the end of 2002, the Vaccine Fund had committed S905 million over five years
to 64 countries in immunisation programme financing. GAVI also proposes to
stimulate the vaccine industry to develop and supply vaccines vital to low-
income countries. The main driver for its inception was the Gates Foundation.
Objectives
0 Improve access to existing vaccine services
0 Promote research and development into new vaccines
0 Raise profile of vaccine-preventable diseases of the poor
Approach
Improvement of access to health products , global coordination mechanism
Main participants
Public sector: WHO, Unicef, World Bank, US Centres for Disease Control &
Prevention (CDC), Ministries of Health in target countries, USAID, UK
Department for International Development (DFID), Canadian International
Development Agency, governments of The Netherlands, Norway, etc.
Private for-profit sector: GlaxoSmithKline, Aventis, International Federation of
Pharmaceutical Manufacturing Association (IFPMA), American Home Products,
Chiron Vaccines, BERNA Swiss Serum & Vaccine Institute Berne, CVP at PATH, etc.
Private not-for-profit sector: Bill and Melinda Gates Foundation, United Nations
Foundation, Sierra Leone Red Cross Society, Instilut Pasteur, etc.
Target countries
75 countries
Website
www.vaccinealliance.org
Name
The Global Fund to Fight AIDS, Tuberculosis and Malaria (The Global Fund)
Disease or risk factor focus
HIV/AIDS, tuberculosis, malaria
Brief description
The Fund aims to rapidly disburse grants to increase existing spending on the
prevention and treatment of these three diseases while building on, comple
ment, and coordinate with existing regional and national programs in support
of national policies, priorities and partnerships.
Objectives
In order to fight AIDS, tuberculosis and malaria:
° To attract, manage and disburse additional monies with less bureaucracy for
recipient countries, allowing more effective use of donor resources, and fewer
transaction costs for all
° To direct financial resources where they are needed most and ensure that
they are used effectively
o Reduced death rates, reduced disease transmission rates, increased survival
rate, and control of multi-drug resistance
Approach
Global coordination mechanism
Main participants
Public sector: WHO, World Bank, UNAIDS, USAID, governments of Thailand,
Brazil, Japan, Italy, France, Ukraine, Uganda, Pakistan, China, European Union
Private for-profit sector: may private companies e.g. McKinsey, Eni S.p.A.,
Statoil, Winterthur, KPMG (Thailand), Pricewaterhouse Coopers (Zambia), etc.
Private not-for-profit sector: Bill and Melinda Gates Foundation, Uganda Health
Rights Action Group, Harvard University, GAVI, AIDES, Academy for Educational
Development, Aids Fund, International HIV/AIDS Alliance, Int. Couincil of AIDS
Service organisations. Global Network of People Living with HIV/AIDS, etc.
Target countries
Website
www.globalfundatm.org
Name
International Partnership Against Aids in Africa (IPAAA)
Disease or risk factor focus
HIV/AIDS
Brief description
Established in 1999, the IPAAA is a coalition housed in UNAIDS, that works
under the leadership of African countries to save and improve lives. It is made
up of African governments, the United Nations, donors, and the private and
community sectors. The Partnership's mission is to reduce the number of new
HIV infections in Africa, promote care for those who suffer from the virus, and
mobilise society to stop the advance of AIDS.
Objectives
0 reduce the number of new HIV infections in Africa
0 promote care for those who suffer from the virus, and mobilise society to
stop the advance of AIDS
0 reduce human, social and economic erosion due to AIDS in Africa
Approach
Main participants
Global coordination mechanism
Public sector: WHO, UNAIDS, FAO, UNDP, UNFPA, ILO (International Labour
Organisation), EU, Canada, European governments (e.g. Belgium, Italy, Finland,
France, Ireland, Netherlands, Norway, Sweden, UK), Japan, US, African govern
ments, etc.
Private for-profit sector: Boehringer-Ingelheim, Bristol Myers Squibb, Glaxo
Smith Kline, Merck, F. Hoffman, Chevron Oil, Eskom, Rio Tinto etc.
Private not-for-profit sector: Bill and Melinda Gates Foundation, Rockefeller
Foundation, McArthur Foundation, Packard Foundation, Ted Turner, African
Council of AIDS Service Organisations, Network of people living with HIV/AIDS
(NAP+), Society of women with AIDS in Africa (SWAA), etc.
Target countries
Website
www.unaids.org
27
Name
Roll Back Malaria (RBM)
Disease or risk factor focus
Malaria
Brief description
RBM is a WHO-led programme ■ a 'global partnership' • that aims to act as global
coordinator for malaria prevention & treatment efforts: specifically, "aims to
provide global leadership, strategy, and overall coordinating mechanisms ", It
proposes to “halve the world's malaria burden by 2010“ and acknowledges the
profound economic and human impact that malaria has on the poor, especially
in sub-Saharan Africa. It was founded in 1998 by four multilateral institutions:
WHO, UNICEF, UNDP & the World Bank, possibly in a reaction to the perceived
failure of the WHO's previous malaria control strategies from the last 40 years.
It is not a fund. It coordinates other stakeholders, other alliances, and funds.
From inception in 1998 its aim has been to apply a new type of management
structure to the application of disease-specific programmes at WHO: more
flexible, less top-heavy, faster at making decisions.
Objectives
0 Increase global political commitment to tackle malaria more effectively
through coordinated action
0 Assist the health sector to focus resources on high disease burdens such as
malaria and cost-effective intervention packages and increase commitment
among the research community and private sector
0 Discover new products and cost effective control tools
Approach
Main participants
Global coordination mechanism, health services strengthening
Public sector: WHO, Unicef, World Bank, US Centres for Disease Control &
Prevention (CDC), UNDP. Ministries of Health in target countries, USAID, UK
Department for International Development (DFID), Canadian International
Development Agency, governments of Australia, Denmark, Ireland, Norway,
Sweden, The Netherlands, etc.
Private for-profit sector: GlaxoSmithKline, Novartis, Eni, ExxonMobil, Procter &
Gamble, World Alliance for Community Health (founder members are mining
companies), etc.
Private not-for-profit sector: Bill and Melinda Gates Foundation, Medecins Sans
Frontieres, Child Survival Collaborations and Resources Group, Red Cross,
Oxfam, MERLIN, Netmark, Malaria Consortium UK, Multilateral Initiative on
Malaria, Medicines for Malaria Venture, Malaria Vaccines Initiative, Royal
Tropical Institute, Netherlands, London School of Tropical Medicine, etc.
28
Target countries
103 countries
Website
www.rbm.who.int
Name
Stop TB Partnership
Disease or risk factor focus
Tuberculosis
Brief description
Stop TB is a partnership that is hosted by the WHO with the aim of eradicating
TB worldwide within the next 50 years or so. Its function is to lead, coordinate,
strategise and plan interventions worldwide. DOTS is the central plank of its
strategy. It recognises the social, political and economic factors that lie behind
the disease TB. It has a strong focus on the link between HIV and TB. Countries
include target countries, bilaterals and multilaterals, academic institutions (tea
ching & research), TB associations, NGOs & commercial pharmaceutical compa
nies. Governance is addressed by the Stop TB Framework and plans and activi
ties are coordinated by the Stop TB Coordinating Board. Founded in 1998.
Objectives
Build partnerships to accelerate social and political action to stop the unneces
sary spread of tuberculosis around the world
Approach
Main participants
Global coordination mechanism
Public sector: WHO. Unicef, World Bank, US Centres for Disease Control &
Prevention (CDC), TDR, Ministries of Health in target countries, USAID, UK
Department for International Development (DFID), Canadian International
Development Agency, US National Institutes of Health (NIH), governments of
Japan, Netherlands, UK, etc.
Private for-profit sector: Pan American Institute of Highways, Soros Foundation,
Wyeth, Ryder-Cheshire, etc.
Private not-for-profit sector: Management Sciences for Health, Royal
Netherlands Chemical Society, International Union Against Tuberculosis And
Lung Disease, American Lung Association, Royal Netherlands TB Association,
Tuberculosis Research Centre, India, Research Institute of Tuberculosis, Japan,
Sao Paolo University, etc.
Target countries
Afghanistan, Bangladesh, Brazil, Cambodia, China, The democratic republic of
the Congo. Enthiopia, India. Indonesia, Kenya, Mozambique, Myanmar, Nigeria.
Pakistan, Philipines, Russian Federation, South Africa, Tanzania, Thailand,
Uganda, Vietnam, Zimbabwe
Website
www.stoptb.org
7. Interesting websites
www.wemos.nl/english
www.ippph.org
www.haiweb.org
www.gatesfoundation.org
www.who.int
8. References
(i) World Health Organisation,
Macro-economics and Health: Investing
in Health for Economic Development.
Report of the Commission on Macro
economics and Health, chaired by
Jeffrey D. Sachs, Geneva, 2001.
(2)(4) Buse, K. (2004). Governing PublicPrivate Infectious Disease Partnerships.
Brown Journal of World Affairs, X(2),
225-240.
(3) Act Up Paris, "Accelerating Access”
serves pharmaceutical companies
while corrupting health organizations,
Press release May 15, 2002.
(5) The Vaccine Fund, The Review, 4,
October 2003. www.vaccinefund.org
(6) Health Action International (2001).
Immunisation for All? HAI-Lights 6 (1).
(7) Save the Children, New Products into
Old Systems, London, 2001.
9. Explanation of words and abbreviations
Accountability
Providing an explanation for or justification of one's actions.
Civil society
Civil society covers the space between the activities of the state and the market.
Organisations within civil society range from church groups to environmental pressure
groups to local credit collectives and trade unions.
Cold chain
The equipment and people that keep vaccines cold, from the manufacturer to the
child. This includes vaccine refrigerators and vaccine carriers. A cold chain failure,
where vaccines have not been kept at specified temperature, can result in vaccines
losing their potency.
Empowerment
The conferment of a sense of self-actualization or authority to an individual, group of
individuals or an organisation
Generics
Drugs not protected by trademark (Exampler'Acetaminophen' is the generic form of
the
proprietary drug'Tylenol')
GPPI
Global Public Private Initiative: a collaborative relationship that transcends national
boundaries and brings together at least three parties - among them a corporation
and/or industry association and an intergovernmental organisation - so as to achieve
a shared health creating goal on the basis of mutual agreed and explicitly defined
division of labour
Health systems
The combination of a set of cultural beliefs about health and illness that forms the
basis for health seeking and health promoting behaviour, the institutional arrange
ments within which that behaviour occurs, and the socio-economic, political and
physical context for those beliefs and institutions. Or: all activities whose primary
purpose is to promote, restore or maintain health (WHO 2000).
Low and lower
A country having an annual gross national product (GNP) per capita equivalent
middle income
between 735 US dollar and 2935 US dollar in 2002. At that time, there were about
countries
64 low-income countries and 54 lower middle income countries.
Multilateral
International institutions with governmental membership.spanning several regions,
organisations
including financial institutions such as the World Bank and IMF, UN agencies and
regional groupings.
NGO
Non-Governmental Organisation: not belonging to orassociated with a government
Pentavalent
A pentavalent vaccine combines 5 different vaccine antigens that can be given as a
single shot; in this case it is the addition of Hepatitis B vaccine and Haemophilus
influenzae type b vaccine to the existing Diphtheria-Tetanus-Pertussis (DTP) vaccine
Private sector
The private sector is composed of all the organisations and individuals outside the
Quadravalent
A quadravalent vaccine combines 4 different vaccine antigens that can be given as a
direct control of the state, including both those working for-profit and not-for-profit
single shot; in this case it is the addition of Hepatitis B vaccine to the existing
Diphtheria-Tetanus-Pertussis (DTP) vaccine
Public health
The general health of a community and the practice and study of ways to preserve
and improve this. It includes health education, sanitation, control of diseases, and
regulation of pollution.
Sustainability
The ability to autonomously continue an intervention after external financial and
TB
Tuberculosis
Transnational
Companies which operate in more than one country but retain ownership and control
technical assistance ceases
Corporations (TNCs): in their home countries
Transparency
In the case of GPPIs, it means that information is open and accessible to everyone and
that decisions are taken democratically
UN
United Nations
WHO
World Health Organisation
WHO guidelines
Guidelines intended primarily to help WHO staff interact appropriately with commercial
on working with
enterprises and avoid conflict of interest
the private sector
HO. About this publication
Text
Tony Sheldon and Wemos
Research
Matt Gordon and Patricia Morton
Design
ingerdesign, santpoort
Financial contributions
NCDO, Ministry of Foreign Affairs, Plan Nederland,
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This booklet provides
on the backgrou
of Global Public Private Initiatives
in health-GPPls, whicf
improve the health situation in
poor countries. It also contains
Wemos Foundation
NORTH SOUTH PARTNERSHIP
FOR HEALTH SYSTEMS
RESEARCH:
20 YEARS OF EXPERIENCE OF
EUROPEAN COMMISSION SUPPORT
STUDY
Report to the European Commission
Summary version
EUROPEAN
RESEARCH AREA
INTERNATIONAL SCIENTIFIC COOPERATION
Interested in European Research?
RTD info is our quarterly magazine keeping you in touch with main developments (results, programmes, events,
etc). It is available in English, French and German. A free sample copy or free subscription can be obtained
from:
European Commission
Directorate-General for Research
Information and Communication Unit
B-1049 Brussels
Fax (32-2) 29-58220
E-mail: research@cec,cu.int
Internet: http//europa.eu.int/comm./research/rtdinfo/index_en.html
EUROPEAN COMMISSION
Directorate-General for Research
International Scientific Cooperation
Unit N.2 - Community cooperation activities
E-mail: inco@cec.eu.int
Contact: Dr Anna KARAOGLOU
European Commission
Office SDME1/17
B-1049 Brussels
E-mail: anna.karaogloucec.eu.int
***
**
it
** *
EUROPEAN COMMISSION
RESEARCH DIRECTORATE-GENERAL
International scientific cooperation
Acting Director
Brussels, 8 November 2004
D(2004)33904
Dear Participant,
I am pleased to provide you with a copy of the summary version of a report entitled
'"North South Partnership for Health Systems Research: 20 years of experience of
European Commission support”.
International Cooperation (INCO) has funded more than 70 projects on health system
research and on health policy for the past 20 years. The need expressed by the research
community to have a linkage between health systems research and policy making and
research initiatives on health system research and health policy triggered the idea of
looking into past and ongoing research in the field, and analysing the work funded for
more than 20 years. The EC convened 10 independent experts from the EU and from the
South to review this work.
This summary report will be diffused and discussed during the working session that the
EC will organise at the Ministerial Health Summit in Mexico on the 17th of November.
The full report will be available after the Summit.
The intention is that this report contributes to a constructive dialogue on health system
research and future challenges. The Mexico Ministerial Health Summit is an important
platform both to disseminate the outputs of the EC health system research of the INCO
programme and to explore the issues particular to health systems research that have been
identified in the course of its involvement in this area.
inn
Commission europeenne, B-1049 Bruxelles / Europese Commissie, B-1049 Brussel - Belgium Telephone: (32-2) 299 11 11
European Commission
NORTH SOUTH PARTNERSHIP FOR HEALTH
SYSTEMS RESEARCH:
20 YEARS OF EXPERIENCE OF EUROPEAN COMMISSION
SUPPORT
Summary version
A report to the European Commission by independent experts
Wim Van Damme (Belgium)
Hans-Jochen Diesfeld (Germany)
Andrew Green (United Kingdom)
Meri Koivusalo (Finland)
Sanguan Nitayarumphong (Thailand)
Goran Tomson (Sweden)
,)
This report has been prepared under contract with independent external experts and paid from
funds provided by the European Commission. Its findings are solely those of its authors and
does not engage the European Commission
Directorate-General for Research
International Scientific Cooperation Policy
2004
LEGAL NOTICE
Neither the European Commission nor any person acting on behalf of the Commission is responsible for the use
which might be made of the following information.
The views expressed in this publication are the sole responsibility of the author and do not necessarily reflect the
views of the European Commission.
A great deal of additional information on the European Union is available on the Internet.
It can be accessed through the Europa server (http://europa.eu.int).
© European Communities, 2004
Reproduction is authorised provided the source is acknowledged.
The publication can be found at:
http://europa.eu.int/cornm/research/iscp/index en.cfm?page=Publications&tvpe-other
Contents
Acknowledgements................................................................................................................................... i
Acronyms.................................................................................................................................................. ii
Executive Summary and Recommendations............................................................................. 1
Health systems..................................................................................................................................... 1
Health systems research (HSR)........................................................................................................ 1
European Union policies.................................................................................................................... 1
European Commission support to health systems research in developing countries.............. 2
Recommendations ............................................................................................................................... 2
2
Background to the report...............................................................................................................5
Health systems................................................................................................................................ 5
3
4
Health systems research................................................................................................................. 8
5
The European Union, and Health Systems and Development Policies.............................. 11
6
EC support to Health Systems Research and Capacity-Building........................................ 12
Programme overview....................................................................................................................... 12
Analysis of EC sponsored HSR projects...................................................................................... 15
Production of knowledge, dissemination and impact on health systems development....... 20
Strengths and weaknesses of the INCO set-up and procedures............................................... 21
Capacity-building and Getting Research into Policy and Practice..........................................22
Health Systems Research System.................................................................................................. 24
1
Acknowledgements
The team would like to thank various people for their inputs to and support for this piece
of work. Firstly, the external reference group comprising Drs Mary-Ann Lansang
(Philippines), Delia Sanchez (Uruguay), Andrew Kitua (Tanzania) and Yogan Pillay (South
Africa) have provided invaluable technical input to the report. Secondly, colleagues in all
the institutions of the authors have provided informal support; particular thanks are given
to Ana Paula Kallstrom (Karolinska Institute) and Tolib Mirzoev (Nuffield Institute) for
their research assistance. Lastly, special thanks are due to Dr Anna Karaoglou and her
staff in INCO-DEV for their support and openness during the process. As is usual, the
authors however retain full responsibility for the content of the report.
Acronyms
ACP
AEDCO
AHPSR
COHRED
DC
EC
ERA
EU
FP
GA VI
GRIPP
GTZ
HSD
HSR
IHPP
INCO-DEV
INCO-DC
MDG
NIS
RTD
STD
SWAp
TDR
TRIPS
WHO
African, Caribbean and Pacific countries
European Aid Office (of EC)
Alliance for Health Policy and Systems Research
Council on Health Research for Development
Developing Country
European Commission
European Research Area
European Union
Framework Programme
Global Alliance for Vaccines and Immunisation
Getting Research into Policy and Practice
German Technical Cooperation
Health System Development
Health System and Policy Research
International Health Policy Programme
International Co-operation and Development
International Co-operation with Developing Countries
Millennium Development Goals
Newly Independent States
Research and Technology Development
Scientific and Technology for Development Programmes
Sector Wide Approaches
UNDP/World Bank/WHO Special Programme for Training
in Tropical Diseases
Trade-related aspects of intellectual property rights
World Health Organisation
1
Executive Summary and Recommendations
Health systems
Health systems have been undergoing significant changes in recent years yet these changes are often
not based on robust evidence.
A greater understanding of how health systems do, and do not, function is a fundamental prerequisite
to improving health in developing countries. Policies to scale up add a further dimension to the need
to understand health systems.
Global factors are increasingly influencing the functioning of the health sector and require policy
attention.
Health systems research (HSR)
Health system research is a relatively new field of research which examines the interactions between
functions, elements and actors in the health system. There have been a number of initiatives in recent
years to strengthen HSR, yet there remain important challenges.
There is a need for increased levels of research funding for HSR.
Clear and transparent processes for identifying and prioritising health system issues for research are
required.
An appropriate balance between applied and theoretical research and also between mainstream and
risk-taking HSR is needed. Adequate provision for longer-term and conceptual and methodological
research is also required. The relative youth and complexity of HSR suggests the need for continued
attention to strengthening of its methods basis.
Greater research leadership and ownership by developing country institutions is needed. This requires
investment in capacity-building activities.
Urgent attention is needed to find ways of addressing the Know-Do gap including seeking early
interest in the research by policy-makers and identifying ways of sharing research findings
appropriately through Getting Research into Policy and Practice (GRIPP).
European Union policies
Health systems in the European Union (EU) are based on values including solidarity and universal
access to services, which provide a basis for EU external action on health.
European States are diverse and include a number sharing similar problems and health system
characteristics with developing countries. Important insights in both directions can be gained
especially from analysis of health policies, pharmaceutical policies, decentralisation and the impact of
globalisation on health systems.
1
European Commission (EC) policies support international health systems research. However, specific
support will be required to ensure that this is not compromised by narrowly oriented research needs
and policy priorities addressing only specific problems.
The challenge facing EU policies in development and health is to ensure that priorities are not
compromised on the basis of increasing focus on internal markets and policies on trade and security.
This challenge of coherence and capacity warrants more, rather than less, emphasis on analytical
skills and knowledge on health systems within the EU.
European Commission support to health systems research in developing
countries
The EC has, over the 20 years of HSR support in INCO-DEV, made a significant contribution to
funding HSR and building the capacity of institutions and individuals in both Europe and developing
countries and has contributed to the creation of solid partnerships.
There are, however, areas in which such support could be made more effective through improved
prioritisation and administrative procedures.
There is potential for further HSR learning and capacity development and transfer of existing
knowledge through equitable North-South, South-South and South-North partnerships which should
be further encouraged.
Capacities, both for research and for using research findings particularly in developing countries, need
further strengthening requiring greater investment by the EC in this area.
Inevitable tensions between competing priorities for funding remain and this reflects a lack of a
current clear prioritisation mechanism.
Further efforts are needed to promote Getting Research into Policy and Practice (GRIPP) in the
INCO-DEV programme. This suggests the need for more understanding of the constraints and
resultant strategies to overcome the Know-Do gap.
The Mexico summit provides an important opportunity for exploration of the general issues explored
in this report and their interrelationships as part of a health system research system
Recommendations
General recommendations
1.
The research community and other key actors should engage more closely with funding
agencies and policy-makers to convince them of the benefits of increased investment in HSR
and capacity-building and help them to understand the context within which research
institutions operate.
2.
International agencies including the EC must urgently and significantly scale up their
funding for HSR.
3.
Support should be given by international agencies, including the EC, to the development
and maintenance of Regional Health System Observatories to collect and disseminate
regionally based evidence.
2
Recommendations to the EC
4.
The EC should develop a more structured and open approach to prioritising health systems
research calls involving both the research community and key southern stakeholders. This
should include specific ring-fenced funding for methods development in HSR and support to
conceptual and long-term research alongside support for medium-term research and
capacity development.
5.
The EC should continue to support capacity-building of institutions both through INCODEV and development funds in both the South and the North. This should include:
•
•
6.
The EC should, in INCO-DEV, give greater emphasis to GRIPP, through:
•
•
•
•
•
•
•
7.
A requirement that capacity-building is seen as a key component of every
project
Capacity-building support for policy-makers to use and interpret research
findings.
commissioning work to understand better the process, by sharing experiences
in this field, or by requiring specific attention to it in project design
enhancing the capacity ofpolicy-makers to use research findings
widening the current criterion of ‘dissemination’ to ‘GRIPP’
fostering national partnerships involving researchers, practitioners and policy
makers as it has fostered international research partnerships
involvement of key parties in the identification of research topics and in the
development of the research
greater attention and investment in dissemination methods
links to development resources to implement findings
The EC should build on the values of universal access and solidarity in European health
systems through:
• encouraging comparative study (North-South, South-South and South-North
directions) of health systems based on similar values
• explicit extension of these values to the global stage through increased support
for developing country health systems
8.
The EC must seek ways of strengthening collaboration between INCO-DEV and AIDCO to
ensure cost-effective use of research data and GRIPP in the EC context. Both Directorates
need to strengthen their analytical capacity and develop linkages which will also serve as an
example of good practice for national health systems.
9.
The EC INCO-DEV needs to find ways for optimal coordination with other key actors at the
global and national levels. The Mexico summit meeting is a platform for strengthening that,
capitalising on the presence of high level policy-makers enabling instant feedback and
recommendations.
10.
The EC should use a variety of instruments to support HSR, some allowing for long-term
funding of larger endeavours, but others more appropriate for exploratory, innovative or
more reactive research, which may thrive better in smaller projects, with shorter time
frames and with simplified approval mechanisms.
11.
The EC should simplify its application (including web pages) and project management and
reporting procedures, making them more transparent and streamlined, and strengthening
3
its support to, and training for, administrative coordinators. It should develop further its
electronic database as a means of monitoring research projects.
12.
The EC should, in the interest of fostering equitable participation, encourage the submission
of more proposals from co-ordinators in Southern institutions and should consider
improving the instruments to create national networks through platforms and the
possibility of granting ‘seed money’ to allow prospective research partners to meet to
compile a full proposal.
13.
The EC should give greater encouragement to the use by researchers of pre-proposal checks
and feedback on outline proposals.
14.
The EC should support a regular forum of EC funded researchers, policy-makers and
practitioners to share ideas, methodologies, and research priority concerns and to provide a
means of dialogue with the EC on issues related to project management. Other forms of
information sharing such as web-sites could also be considered.
2 Background to the report
This document is a summary of a more extensive report12 commissioned by the EC Research
Directorate into the experiences of its research programme on health systems in developing countries
over the last 20 years. The EC has, in recent years, put significant effort into supporting research into
health system questions. It has recognized however that greater efforts are needed to identify the
appropriate knowledge gaps on health systems, and find answers to these in ways that will be
implemented. The EC has also developed a particular way of funding research which, for example,
lays stress on collaboration in research endeavour between Northern and Southern partners. The
report should be seen as a case-study of one international agency’s response to the need for HSR
which has wider lessons for other such agencies.
The report was commissioned in recognition of the key role that health systems play in promoting
health objectives. It is expected that the report will serve two complementary purposes. Firstly the
EC itself will use the results in considering improvements to its future INCO-DEV research
programmes. Secondly the report will provide an input to the 2004 Mexico summit allowing
ministers to learn from the successes and failures of one particular approach as they seek means of
strengthening the health systems research processes. It is one of a number of activities within this
area at this time such as the Independent Task Force convened by WHO and the Activities of the
Alliance for Health Policy and Systems Research including an recent evaluation.
The full report has drawn on a number of sources. These include secondary data, which included a
review of final reports related to a sample of specific projects, and a limited number of interviews
with key informants as well as a literature review. An important part of the process has included peer
review and validation by a separate reference group who joined the team for a workshop in Brussels
as part of the drafting process.
Within the report, the term Health System Research is used to include Policy-focused research, and
the acronym HSR to cover the wide inclusive interpretation.
3 Health systems
Health systems throughout the world are facing an increasingly urgent set of challenges. Gross
inequities in health at the global (and frequently national) level - illustrated for example by the fact
that the lifetime risk of maternal death is over 100 times greater in Africa than in high income regions
of the world - are being exacerbated. For many countries health systems are failing to deliver
improvements in health. Whilst this is particularly the case in sub-Saharan countries where AIDS,
coupled with the other major killers of malaria and TB, are having devastating effects, these failures
to achieve health improvements can be found in vulnerable populations throughout the world where
such vulnerability is caused by a combination of social, economic and political factors. The particular
socio-economic and other contextual differences of countries lead to different patterns of ill-health
and the need for different health system responses. Despite goals that range from the Health for All
by 2000 objectives of the Primary Health Care movement through the ICPD charter to the most recent
Millennium Development Goals (MDGs), there remains a widespread sense of health system failure.
1 The full report is obtainable from Dr Anna Karaoglou, (anna.karaoglou@cec.eu.int ), European Commission DG Research, International Scientific Cooperation, SDME 1/17 B-1049 Brussels, Belgium
The full report also contains the full references referred to in this summary.
5
Clearly if there is to be a serious attempt to meet the MDGs, the performance of the health system
must be improved, and as a matter of urgency. This is particularly the case if health systems are to act
effectively as a platform for scaling up efforts such as WHO’s 3x5 initiative.
Yet for this to occur, the critical question of how must be answered. The last 15 years has witnessed
an unprecedented set of serious attempts to re-engineer the health systems of many countries both low
and high income. Against the background of wider structural adjustment policies which sought to
reduce the role of the public sector in developing countries, the World Bank led a set of health sector
reform policies in the 90s which were rooted in neo-liberal market based policies. In particular the
public sector reforms included a changing role in the public sector from service provision to policy
direction and regulation and greater reliance on the provision of health services by the private sector
which was perceived as more efficient. Linked to this was the concept of the purchaser-provider split
and the introduction of public sector quasi-markets as part of general “marketization” of the health
sector. Inefficiencies were also seen to result from over-centralisation. As such, reforms included
attempts to decentralise decision-making to district levels and semi-autonomy for (particularly
tertiary) hospitals and movement from vertical programs towards more integrated approaches.
Reforms also frequently included the introduction of new health financing methods and in particular
user fees and more recently, social insurance. The financing crisis put new emphasis on the need for
priority setting and new forms of resource allocation, and reforms often included essential health
packages and new processes of priority-setting based on cost-effectiveness techniques.
Health reform initiatives focused on introducing structural and financing changes in health systems.
This focus led to the neglect of a number of issues. In particular reforms have been criticised for
placing insufficient emphasis on staff issues, demand-side issues such as community involvement and
needs assessment, and ignoring the overall low levels of available resources as the major constraint
facing such health systems. The latter was highlighted by the Commission on Macro Economics and
Health report which suggests that the funding gaps are so large as to require significant international
financing (potentially through new mechanisms such as SWAps). The reforms were also criticised for
a focus on health services rather than the broader objectives of health, thus neglecting the potential for
inter-sectoral health promoting activities.
The manner in which reforms were introduced was also criticised as being top-down, internationally
imposed and, most importantly in the context of this report, evidence-poor.
The above does, however, suggest that the last 15 years has witnessed increasing interest in health
systems and their internal workings. This has been shown in both greater conceptual thinking about
health systems (such as evidenced by the WHO framework which is elaborated on in Figure 1), and
recognition of the importance of understanding the challenges they face and the opportunities they
provide to improving health. It has also seen controversial attempts to measure and indeed compare
the performance of health systems.
6
Figure 1: Function/action-based view on health system
Source: based on Murray and Frenk, 2000
Alleviating health
distribution
inequalities within
population
Improving
average level of
population health
------------------------
This period has also seen an unprecedented rise in global influences on health. These range from
global political and economic initiatives to those that are more health specific. The implications of
some of these are still to emerge clearly. However within the health sector, growth of Public Private
Partnerships (such as GAVI - the Global Alliance for Vaccines and Immunisation and the more recent
Global Fund for AIDS, Malaria and TB) are seen by some analysts as major new forces. Whilst set
up as mechanisms for tapping funding, they are also viewed in some quarters as the birth of a new
form of international verticalisation, and criticised for diverting resources away from the broader
health system which is seen as a necessary platform from which to scale up responses to these major
diseases. Who for example, given the human resource crisis in Sub-Saharan health systems, will be
available to scale up access to ARV treatment? Their governance and accountability back to national
health systems is also questioned raising issues as to where policy power now lies.
The health system changes described above were, however, often based on, at best poor evidence of
what works, and at worst, crude ideology. Despite calls for greater evidence-based decision-making,
7
led by agencies such as WHO, the reality is that there are huge gaps in our understanding of how
health systems operate, and what policies could feasibly be deployed to improve them. In particular
at present there are no international mechanisms for sharing experiences between countries or regions.
There remains a significant imbalance in the level of research effort between the search for technical
answers (such as new drug developments) compared to system answers (such as how successfully to
deliver proven therapies). A classic example of this lies in TB, the cause of 2 million deaths per year,
where there is significant knowledge of the clinical requirements for TB detection and treatment, but
far less understanding of the constraints to ensuring appropriate access and utilization of these
therapies. Furthermore, even where there are robust answers to health system questions, these may
often be ignored by health policy makers, leading to the infamous ‘Know - Do’ gap.
Greater globalisation is also bringing new challenges to national health systems including traderelated agreements and trade in health services, intellectual property rights and migration of
professionals. Globalisation is based on political processes with a need for change in global
governance and economic and trade policies. In the context of trade policies special attention needs to
be drawn to multilateral and bilateral agreements concerning trade in services and intellectual
property rights. Globalisation brings opportunities, but these are not without costs including over
equity and universal provision of services. There is a need for further attention to international
collaboration and regulatory measures including those related to human resources.
In order to support national health systems a new focus on global regulatory measures, standard
setting as well as evaluation of new technologies and products for the benefit of health systems and
national health policies will be required.
4
Health systems research
The above has suggested that there is increasing recognition of the importance of strengthening health
systems and hence a critical need for greater understanding of how they operate and the challenges
they face. Health systems research (HSR) has improved our understanding of who uses health
services and why, challenged medical claims about the value of specific interventions, helped shift the
balance from practitioners’ to patients’ concerns, identified ways of improving the financing,
organisation and management of services, improved our understanding of the impact of new
technology and contributed to improve the performance of services. However to improve the
performance of health systems in low and middle-income countries it is necessary to scale up the
efforts in research at every level, including local, national and international in different areas such as
financial and human resources, organisation and delivery of health services, governance, stewardship
and knowledge management.
Whilst there are a number of definitions we define Health Systems Research (HSR) as:
‘the production of new knowledge and applications to improve how societies
organize themselves to achieve health goals, including how they plan,
manage and finance activities to improve health, as well as the roles,
perspectives and interests of different actors in this effort' (AHPSR 20000)
Figure 2 sets out graphically the characteristics of HSR.
8
Figure 2: Health Systems Research Characteristics
Health Systems Research Characteristics
Despite its critical importance, health systems research is relatively new with its origins as a separate
area of investigation distinct from the more well-known area of clinical and laboratory research being
only 20 - 30 years ago. The youth of the discipline brings inevitable challenges, particularly where it
is contrasted, and indeed competing, with the more established biomedical research approaches.
Such challenges are firstly methodological.
Whilst there have been significant strides in
methodological development over the last 25 years, challenges remain. The nature of the questions
investigated in health systems research requires contributions from many disciplines including, for
example, economics, sociology, anthropology, epidemiology, operational research, and political
science, and the use of both qualitative and quantitative research methods. How such disciplines can
be combined in a genuinely multidisciplinary way poses new methodological challenges. The
appropriate balance between disciplinary specialism and broader multi-disciplinarity is also difficult
to gauge and achieve. Furthermore, breaking new methodological ground poses risks to researchers
which funding agencies need to recognise and be prepared to accept
Related to the above, is the importance of context in health system research. Each health system is
unique in terms of the range and combination of factors affecting it. This raises issues in terms of
how to interpret HSR and in particular its generalisability versus its context-specificity.
Furthermore, many HSR questions require significant time periods to answer. Changes in health
systems can be slow and not identifiable within the short time frame available to many research
projects, or acceptable to funding agencies. Health system research needs to find an appropriate and
acceptable balance between short-term and long-term research.
There are also ethical issues in health systems research. 'Each research domain has its own ethical
challenges - with those of biomedical and laboratory research being well-known. Health system
research faces a number of challenges including those of confidentiality, treatment of values (such as
equity), and approaches to socially sensitive areas such as corruption. It also raises questions as to the
use and ownership of findings (for example between communities and researchers) and the need for
greater participation by the subjects of the research in the actual conduct of research. Underpinning
9
these concerns is the recognition that HSR deals with issues that relate to relative power between
different actors within the health system.
The complexity and ever-changing nature of the health system means that there are, and always will
be, a myriad of questions which HSR can usefully attempt to answer. There have been various
attempts to identify such topics (such as by the Alliance and in the Lancet). Box 1 sets out a number
of examples of topics that we would suggest are currently under-researched. However such list is
personal and has no claim to basis in a scientific methodology. Rather, it is an illustrative list. It does
raise however two further challenges for HSR.
Box 1: Examples of neglected or emerging HSR topics
Importance of the Health System to MDGs
Prevention and role of the health care sector in cross-sectoral promotion
a. Role of public policy measures in prevention and promotion of health;
b. Effectiveness of different incentive leverages in promoting cross-sectoral collaboration.
Community/Demand side/Civil society
a. User involvement in health care;
b. Community and citizen views;
c. Gender issues in health and health care.
Governance in the health system
a. Mechanisms and systems;
b. Corruption;
c. Regulatory measures in health systems;
Global aid and trade policies and health systems
Globalisations including the need for regulation and pressures of commercialisation in health care.
Non-financial incentives in health systems.
Scaling up.
Integration of essential vertical programme into health system.
Human resources issues including international migration
Accreditation.
Private sector
How to make effective links between Evidence, policies and practice.
Firstly, it is clear, and has been acknowledged in a number of quarters, that insufficient resources are
put into HSR. Whilst funding levels have increased significantly in recent years, not least in agencies
such as the EC, HSR is still the poor cousin when compared to biomedical research. In the recent
publication from The Alliance for Health Policy and Systems Research (2004) Strengthening health
systems: the role and promise of policy and systems research, it is estimated for example, that 0.02%
of total health expenditure is allocated to health systems research. Yet many of the challenges facing
developing country health systems are system-based rather than biomedical. For many health
problems, technical solutions exist, but are not (effectively) applied through weaknesses in the health
system.
Related to the above are concerns as to the availability of research capacity. Research institutions
face particular pressures. For example within Europe core support to research institutes is declining
and there are pressures on researchers which may conflict with their mainstream research work. In
many developing countries there is currently very little HSR capacity. Building research capacity
may not always be viewed as high priority by health policy-makers either at the national or
international level and yet, without such capacity, HSR of an appropriate quality is impossible to
achieve.
Secondly, it is also clear that, even if budgets for HSR doubled tomorrow, there would still be a
massive shortfall between research questions and available research funding to answer such questions.
This raises questions as to how priorities are, and should be, set, and in particular by whom, and using
which criteria. HSR needs transparent priority-setting mechanisms at the relevant levels. It remains
10
to be shown whether the CAM model is adaptable to fit this purpose for HSR or if other models
should be developed.
The above issues are well-known to the health system researcher. However less well-recognised is
the gap between health system research and resultant evidence-based action. The Know-Do gap is
still wide and both health system researchers and policy-makers need to pay more attention to how it
can be bridged. The gap appears both at national and international levels. Indeed within the EC itself
there is little interaction between the directorates responsible for developing knowledge and for
applying it.
Strategies such as giving greater emphasis to HSR commissioned by policy-makers appear attractive
as means of increasing ownership of the resultant findings, but raise questions as to the need for a
balance between research topics identified by other including researchers themselves who may have
fewer pressures to take a short-term policy view. Other strategies relate to the mechanisms for
dissemination of results with less focus on traditional academic dissemination means and more on
those likely to be accessible by policy-makers and users of services.
Q
5
The European Union, and Health Systems and Development
Policies
The division of European Community health policies between public health policies and health
services has meant that health systems issues as a whole have not been the subject of EU policies.
There has not been substantial accumulation of expertise and knowledge on health systems. The
unclear mandate has also led to fragmented approaches between two DGs: Health and Consumer
Affairs and Social Affairs and Employment. European health policies have become increasingly
influenced by decisions and processes outside the health sector. European Court of Justice decisions,
the quest for competitiveness of the European economy, industrial policies and protection of interests
of European industry and the developments of internal markets have all set the context for health
services, pharmaceutical policies and public health policies, leading to consideration of health systems
increasingly as part of the economic and commercial interests.
The EU involvement in research and development intersects EU health policies at various levels. The
commitment to ensure a high level of health protection in all policies is of relevance to research and
development efforts. Furthermore the EU has also been actively supporting research efforts
concerning health services.
Policies in other sectors may impose substantial cost implications to health systems. The aim of
ensuring consideration of health in other policies has been a challenge for the EU and also is
important in development policies.
EU development aid is substantial and in the field of health carries weight. Therefore it is particularly
important that the EC ensures a strong and analytically based set of health development policies
which includes support to health systems research.
Various European health systems (and in particular those based on Beveridge and Bismarck
principles) embody key values and approaches to health systems development, such as solidarity and
equity of access to health services. The lack of sufficient analytical capacity within the EC to
underpin development strategies carries the danger of the adoption of policies that are not consonant
with these values.
11
INCO-DEV research3 on health systems fits and supports the core development policy efforts on
poverty and health as well as the overall research policy priorities. However there is also a risk that
more targeted measures with respect to poverty-related diseases, HIV/AIDS and research and
development in pharmaceuticals may restrict EU support to health systems development into vertical
programmes and specific diseases.
The international role of the EU is changing. In future the European Commission may play a greater
role in representing member states in international organisations such as WHO. The new strategic
partnership with WHO strengthens their relationship. This highlights the importance research within
the EU on health systems and health policy to ensure that European positions are empowered with
knowledge, analytical capacity and a genuine European approach based on dialogue, research and
analysis and are grounded in European academic and institutional networks and collaboration with
developing countries. However, there needs to be an improvement in transfer of knowledge on
research and programming between the EC directorates. In particular, it is unclear to what extent
INCO-DEV links and resources have been used, and recognised, in the European Community aid
policies.
International exchange is of crucial importance in the context of health sector reform. While it is
necessary to view European solidarity as part of broader European values, it is also important to
recognise the potential for mutual learning and exchange in the context of health policies. In terms of
the INCO-DEV work this suggests more dialogue and exchange between health managers and
researchers involved in research within Europe and developing countries in a context of comparative
studies and analysis.
Finally, globalisation and increasing economic integration create new challenges to health systems in
Europe and the developing world. There is a need and opportunity to further expand and exchange
analysis of health policy priorities and regulatory matters to ensure universal access, cost-containment
and solidarity in health systems. This is important both to articulate concerns about common trade
and intellectual property rights in the sphere of health policies, and to minimise human resource
shortages in developing countries. Research and understanding of health policies in this area needs to
be expanded within the EU. This raises a challenge both in the context of European external and aid
policies and it is important to ensure policy coherence is not sought predominantly on the basis of
trade interests.
6 EC support to Health Systems Research and CapacityBuilding
The EC has been a key funder of HSR over the last 20 years. This review of these experiences may
help both the EC and other agencies to address the above challenges for Health System Development
(HSD) and HSR.
Programme overview
Research co-operation on health with developing countries has been part of the EC’s overall research
agenda under its regular research budget since 1983 and continues to be one of the main priority areas
with co-operation programmes in ACP, Asian and Latin American countries, and Mediterranean
Partner countries, Western Balkans, Russia and the other NIS. The EC’s scientific co-operation for
development has gone through a number of phases as set out in Table 1. While RTD for collaboration
with Developing Countries is only a small fraction (around 0.01 - 0.017%) of the total Framework
Programme research budget it has benefited from the overall increasing research budget (42M€ to
3 Within this report this term is used generically to cover STD1-3/1NCO-DC
12
153M€ between 1983/86 to 2003/2006). The total health research budget within this framework
increased from €10.5m in 1983/86 to €62m in 1998/2002 and remained at 25-30 % with a peak of
35% in 1991/1994. The budget for HSR, as far as data is available for FP4 and 5 is around 30% with
70% for Biomedical Research.
Table 1: Framework Programme 1-6 Budget and RTD Budget for Health and HSR
1983 - 2006
FRAMEWORK
FP
PROGRAMME
period
€ in
Research and
technology
for
Total
budget
€m
Development
Health
budget
€m
(% of
total)
RTD
No.
Health
con
tract
No
HSR
contra
HSR
budget
€m
CIS
(% of
health)
1
1984-87
3,270
STD 1
42
10.5
(25%)
n.a.
n.a.
n.a.
2
1987-91
5,400
STD 2
85
25.5
(30%)
154
n.a.
n.a.
3
1991-94
6,600
STD 3
125
43.7
(35%)
140
26
n.a.
4
1994-98
13,120
INCO-DC
209
62.9
(30%)
154
n.a.
19.6
(31.2%)
5
1998-02
14,900
INCO-DEV
230
62.0
(27%)
63
26
17.9
(28.9%)
6
2002 - 06
17,500
INCO-DEV45
153
50.05
(33%)
n.a.
n.a.
n.a.
Figure 3 shows the evolution of the international cooperation research budget and the health
component over this period and the allocation for funding for health research between developing
countries and the EU.
Figure 3: Evolution of International cooperation Research Budget, EC Research Directorate
General
4 In FP6 specific INCO activities involve all regions (DEV, Mediterranean Partner Countries, Western Balkans,
Russia and the other NIS); the total budget for all regions is 325 M€.
5 This figure is approximate and excludes funding for research into the three diseases (TB, Malaria, HIV/AIDS)
which from 2002 is funded separately. In FP5 in INCO this was at a level of approximately a further 15M€.
13
Figure 4: Allocation of funding for health research (1999-2001) EC Research Directorate
General
Total funding 61,852,308 Euros
These programmes show an interesting shift in approach by the EC. Initially they focused on bilateral
activities between the EU and recipient countries, then on specific programmes in the Framework
Programme structure. Within FP5 a new strategic objective of policy issues was introduced. In
December 2002 the EC launched the first calls for the 6th Framework Programme with a different
structure and philosophy. The innovation is the creation of a European Research Area (ERA) for
better co-ordination amongst European Institutes and open to the world. Developing countries are
now able to access funding in all European Programmes such as studies of European health systems.
In FP6 it was decided through bi-regional dialogues to launch Platforms on health (and other areas)
with the Specific Support Actions instrument with EU and partners from other continents to help
consolidate regional education and research capacities, to innovate technologies and implement,
wherever required, better standardisation in health technologies and methodologies. These EC-biregional dialogues aim to establish priority areas to solve problems specific to those regions. A
Platform is a forum of equal partnerships in Research and Development, where common issues are
identified, solutions formulated and new research proposals formulated.
The development of the EC research programme demonstrates some of the challenges facing any
research funding agency and are outlined below.
Firstly, any research programme needs to have a clear purpose and objectives. For the EC there are
the key principles on which their funding programme are based:
• Thematic approach to all Developing Countries (DCs)
• Partnership based on Europe-DC dialogue; and
• Regional differentiation among DCs.
At a broad level research under this programme is intended to meet the needs of Developing
Countries with a clear link into the development of relevant policy. However there are other key
objectives. These include increasing emphasis on the need for research projects to support the
research infrastructure in developing countries through capacity-building activities with adequate
participation and involvement of such countries in the programme. However there are some inbuilt
tensions in the objectives. Firstly their key objective of supporting developing country health systems
may sit uneasily with the overall Framework objectives to strengthen the scientific and technological
basis of the EC to make it more competitive. Furthermore, the programme was initially (and to some
degree still is) viewed by some European Tropical Medicine Institutions as having a key role in
14
providing support for them. Indeed given the increasing pressure on such institutions to generate
funds this remains a tension in terms of objectives.
Secondly the programme has contributed to getting HSR on the map through the EC role as an
institution that explicitly funded research into health systems and health policy. Linked to the above
has been a role for the INCO-DEV research programme in supporting the development of the role,
concept, definition and methodology for HSR both through project support and through, for example,
support to meetings.
The EC research programme has also explored different mechanisms for funding research projects
including both ‘regular’ research projects and mechanisms to develop networks of researchers already
working in a particular field. Box 2 provides an overview of these.
Box 2: Some instruments used in support to HSR in developing countries
Source: www.cordis.lu (http://fp6.cordis.lu/fp6/calls_activity.cfm?ID_ACTIVITY=532)
Characteristics
Instrument
Coordination action
These are actions (concerted and thematic networks) where
research is ongoing elsewhere and researchers get together for .
concertation or thematic networks where they are ready to
involve all stakeholders to implement research results
Shared Cost/STREP
These are research projects in to new areas of investigation.
STREP (Specific Targeted Research Projects) replaced Shared
Costs projects in FP6.
SSA
Specific Support Actions for wide dissemination of results, for
identification of new research areas and policy implementations
It is also important to recognise that the INCO-DEV programme has faced difficulties, most recently
in 2002 when its individual nature was under threat, with proposals to absorb it into the wider EC
research programmes6. Whilst, lobbying by research institutions contributed to the reversal of this
decision, it is clear that complacency over the sustainability of the programme may be misplaced.
However in FP6 INCO is a Directorate and in FP7 its specificity should be ensured together with the
opening of International Cooperation to all EU programmes.
Analysis of EC sponsored HSR projects
The review analysed completed projects funded in FP4 and FP5 using reports as the primary source of
data. There are limitations to the methodology used which are discussed in the report but the general
conclusions are considered as valid. Boxes 3 and 4 provide case-studies of EC funded support to
HSR in Thailand and Burkina Faso.
6 Kroeger A, Falkenbcrg T, Tomson G et al 2002
15
Box 3: Success story of Thailand HSR and EU contributions
Source: Personal Communication Nitayarumphong S 2004
Thailand was supported to develop a model of integrated healthcare in one province through HSR
from EU fund before and after INCO-DEV up till 1996.
The development of a provincial healthcare model attracted demand from other provinces to
follow the same development, at the same time other ongoing health care development in the
country also need innovative approach to be pushed to go further. This urged to develop a
national project covered the development of integrated healthcare in five other provinces and later
in nine provinces.
The support of EC fund was shifted to DGI development fund started from 1996 to 2000 with the
intention to develop a package of policy and plan for overall healthcare reform in the country.
The outcome of DGI- supported fund did not only end with the outcome of a package of health
policy and plan for reform, but also a model of appropriate healthcare in various provinces and a
draft legislation on universal coverage for healthcare for all Thai citizen.
These products were adopted by the newly elected government in January 2001 especially the
implementation of universal coverage. Lessons drawn from out were that EU had contributed a
certain level of technical assistance from the research project to national program in Thailand and
process of learning through interaction between Thai and EU researchers including networking
with other countries did bring the increase of capacity of human resources to implement the Thai
healthcare reform more effectively.
In addition, more integration among EU different
departments from knowledge to actions could generate a real impact for changes to happen in
health care development.
16
Box 3: Burkina Faso Case-study
Source: Personal Communication Diesfeld, HJ 2004
The development of the Programme for Science and Technology for Development by the EC in 1984
provided the opportunity for collaboration between Heidelberg University, the MoH and the
Department of Public Health, Faculty of Health Sciences University of Ouagadougou. Research was
designed to measure the quality, effectiveness and utilization of preventive and curative health
services at the district and community level and accepted by the MoH and the EC.
The Ministry of Health seconded a national researcher, the Faculty of Health encouraged 3 medical
students to act as junior researchers and Heidelberg seconded a Principal Investigator, responsible.
DED and GTZ provided technical assistance and transport. Field research was completed by 1985
and data analysed in a participatory evaluation with the health services in 1986. In December 1986,
the medical students defended their theses successfully - the first time that medical students did their
thesis work “in the field” of basic health care up-country rather than the protected area of the
University Hospital. In the course of this event a “Partnership” between the Faculty of Health
Sciences Ouagadougou and the Medical Faculty of Heidelberg was officially inaugurated.
As a consequence of the evaluation the Ministry of Health planned a further project for action
research which was again submitted to, and approved by, the European Commission in 1990 under the
title “Action research on the utilization of health services in Burkina Faso” with the Ministry of
Health providing the Principal Investigator. The study, based in Nouna, aimed to assess the output
and outcome of newly organized rural health services. The major policy changes to be tested were:
participation of the target population in financing and management of health services
enhancement of service quality through standardization of medical tasks
increased attraction by better integration of services,
introduction of a delivery system of essential generic drug,
strengthening of mother’s skills in treating key childhood illnesses.
The study population comprised all 6000 households in Nouna hospital catchment and 3 health
centres - around 30,000 individuals. Health impact was monitored through changes in age and cause
specific mortality using censuses and vital events registration and verbal autopsy of all child deaths. A
sub-sample of 600 households was studied by periodic household surveys which yielded information
on changes in health service utilization, health care expenditure and time lost due to illness.
This Demographic Surveillance System (DSS) still exists and enabled the MoFI to become part of the
INDEPTH network (International Network of Demographic Evaluation of Populations and Their
Health) in 1997. The new research programme studied different topics. Several new research
assistants were engaged at the expanding research station in Nouna. The MoFI provided a building
complex within the Nouna District Hospital, a former epidemiological field station. Field
investigators, interviewers and data entry clerks were recruited and trained. Research aiming at
improving child health, equity and efficiency implications of prepayment schemes and health
insurance were undertaken.
The iterative process between MoH and Nouna Research Station and the growing number of
completed research projects led to increasing acceptance of this kind of scientific cooperation by the
MoH. This and efforts to seek further funds alongside favourable developments in the acceptance of
HSR, internationally, within the University of Heidelberg and within the German scientific and
research sponsoring community as well as the Federal State of Baden Wiirttemberg, paved the way
towards establishment by the Burkina Faso Government of a ‘Centre de Recherche en Same de
Nouna’ in 1999 as a national reference centre, in line with EC policy to develop research partnerships
and structures for strengthening European and African research capai iiy.
17
Focus of research projects
Each EC call specifies broad domains, such as "rational organisation of health services’ or "policies
for improved practices’ resulting in a variety of project proposals being submitted and approved.
These are reflected in the titles of the projects funded in FP4 and FP5 (examples are given in the
report), and in the classification of the 43 projects reviewed, according to a typology in 9 categories
(see Table 2).
Table 2: Typology of the 43 research projects reviewed
Determinants of health
Implications of specific health issues
Impacts of intervention
Health sector reforms
Quality of care and of services
Inputs in health systems (human resources, drugs, and
others)
Research methods
Citizen perspective and user involvement
Health policy
1
2
8
10
8
7
1
3
3
There are currently 36 ongoing projects from FP5 and new ones from FP6 in a variety of HSR areas.
The opportunity to choose research topics within a broad arena is valued by researchers, who consider
they can apply for funding for research they prioritised themselves. However, the requirement of
working out detailed plans including deliverables at the stage of submission is also seen to limit the
freedom of research. Some of those interviewed also think that this ‘academic freedom’ is one of the
reasons for the lack of synergy between the EC ‘research for development’ programme and the EC’s
national and regional development co-operation programmes.
The EC is aware of this challenge, and has sought to improve the "relevance for development' of its
health research, especially HSR. Various tracks are being pursued such as promoting the involvement
of practitioners, policy-makers and other stakeholders, as research partners and the review by regional
panels of research proposals which have passed through scientific review to judge on relevance and
relative priorities. However the information on the criteria and processes used by these panels are not
always clearly disseminated.
Concerns have been expressed about these mechanisms, and suggestions made that the EC should
develop procedures, involving a mix of different stakeholders from the South and the North, for
selection of domains of research, and of more specific topics for the calls on which to invite more
focused research bids. Such a process might be part of an annual meeting of such stakeholders
organised by the EC.
Partners and Partnerships
One of the prominent features of the EC research programme is its cooperative nature, both among
European countries, and between European and Southern partners. The creation of a research
partnership is seen as both an end in itself and a means to achieve the research end. As such it is an
absolute pre-condition imposed by the EC for accessing project funding. Initially a minimum of one
European and one Southern partner was required (1:1), but this evolved to a 2:2, and then 3:3
minimum, partly triggered by the requirements of the wider RTD programme.
The increased number of partners (see Figure 5 also led to increased budgets per project. In the 1990s
a typical HSR project had a budget of €400 - 800,000 for 3 or 4 years. Many new projects however
now have budgets of €1,500 -2,000,000 for a similar duration. The current trend is towards
encouraging larger projects and partnerships. However it is considered that a variety of instruments is
18
desirable, some allowing for long-term funding of such larger endeavours, but others more
appropriate for exploratory, innovative or more reactive research, which may thrive better in smaller
projects, with shorter time-frames and with simplified approval mechanisms.
Among the 43 projects reviewed, there was a even split between those with between 4 research
partners - the minimum required in FP4 and FP5, 5-7 and 8-12 partners (see Figure 5). Most
partnerships have similar numbers of partners in the North and the South, resulting in roughly half of
total partners from the North, and half from the South.
Figure 5: Number of partners per project in 43 HSR projects reviewed
Geographical representation
Figure 6 provides information on the source of partners by region. Northern partners are always
European, and Southern partners within one project are usually from the same region. Among
Southern partners, slightly over half are ACP countries followed by, in decreasing order, Latin
America, Asian and Mediterranean. It is understood that there has, in recent years, been an increase
in Asian partners7 (This geographical spread of partners in HSR projects is very similar to the entire
INCO program. Projects still largely focus on research in Southern health systems though there is
potential for greater learning in both directions, particularly given the new Accession countries.
7 Anna Karaoglou personal communication
19
Figure 6: Participation of partners by region for 43 HSR projects reviewed
Types of partners
Among the Northern partners, there is strong representation of Schools of Tropical Medicine and
other academic institutes in international health. In the South there is a strong presence of universities
and research institutes, with some representation of Ministries of Health, co-operation agencies or
civil society organisations. This may reflect one original objective of the international cooperation
component to support research infrastructures.
Quality ofpartnerships
Many partnerships are brought together for the formulation of an INCO research project, and
relatively few are long-standing stable partnerships. Although such ‘dynamic networking’ can be
seen as a factor of the success of the programme, it is also perceived in some quarters as instable and
jeopardising the research.
A positive feature of the INCO-DEV programme has been its concern for equitable partnerships to
attain a balance between institutions in the North and the South at a number of levels including
funding streams and research leadership. This balance has not yet been reached though there appears
to be an increasing number of projects led by Southern institutions and a trend towards more equally
shared budgets.
There are constraints to achieving a better balance including current capacity. Whilst this is partly
being addressed by projects in which capacity-building is a key component,
the North-South
difference in project leadership is still perceived to be substantial. Factors contributing to the
Northern dominance include the costs of project preparation and meetings, the difference in
experience and tradition, and the capacity to disentangle and interpret the information on calls,
priorities and procedures from the EC. Another difficulty reported is a lack of joint development of
research methods arising from the proposal writing process and the complex methodological nature of
HSR.
Production of knowledge, dissemination and impact on health systems
development
HSR faces particular problems in terms of measurement and attribution. Knowledge produced
through research is disseminated to a variety of audiences and through different channels. Publication
in peer-reviewed journals remains the cornerstone of measurement of academic impact, and the main
report gives examples of the many publications arising from EC funded research. However there is
20
little evidence on the relation between such academic impact and societal impact.
Such
considerations lead to a tension for INCO-DEV objectives in terms of attaining a balance between
contributing to science or to development.
For the EC, HSR has a mandate to support health policy and planning. However, whilst the
individual scientific and technical evaluation asks for “deliverables” of the proposed projects and
most research proposals attempt this, there is no mention of the research outcome beyond “expected
outcome” in the project overviews. Indeed the timeframe of INCO-DEV project funding/monitoring
may be too short, with outcomes occurring beyond the funded period not automatically coming to the
attention of the Commission.
Most projects state that ‘research results will influence health policy'. This goal is pursued in
different ways, such as communicating research results to policy-makers, and involving them in the
research to enhance the ownership of results, using results in teaching, writing reports, policy briefs,
and scientific publications.
Few EC-funded HSR research projects are stand-alone. The academics involved in the EC-funded
HSR projects are often located within influential institutions which are also involved in other
development activities and which the research may influence.
One aim of the ‘Accompanying Measures’ (now ‘Specific Support Activities’) in the INCO-DEV
programme is to promote dissemination and use of research results. It is our impression that this
needs further attention. How research feeds into policy, or how policy uses research, is still unclear
for most researchers and policy-makers alike.
The different time horizons between research projects and health policies may also hamper such input.
INCO research projects have typically a 3 - 4 years horizon, while health policies can have very short
or very long timeframes.
However, most researchers interviewed confirmed that many HSR projects did not get beyond the
formulation of recommendations to policy makers, and that they remained often in doubt whether they
had actually been taken up. But most interviewees could point to an example where they thought
research projects had been successful in influencing policy. This was often attributed to the early
involvement of policy-makers in the project. One recognised success where research in Thailand (see
Box 3) evolved through different phases spanning well over a decade, resulting in a major health care
reform for the entire health sector. This resulted from a long-standing North-South collaboration,
spanning various framework programmes, and EC development agreements, in which the researchers
progressively became the policy-makers.
Strengths and weaknesses of the INCO set-up and procedures
Strengths perceived by researchers are that the programme allows considerable freedom for the
researchers to define the research projects, that it works towards equitable research partnerships and
that it supports capacity building, in both the North and South. As in any programme, however, there
are areas where strengthening is required.
Transaction costs
One challenge faced by the EC is to develop administrative procedures which meet accountability
requirements, are efficient, and not too onerous for researchers. There is, however, a perception that
EC funding carries significant transactions costs, which may be a barrier, particularly for small
institutions. In particular the co-ordination of a large partnership is very time-consuming, during both
the preparation and management of the project. Investment in proposals is, of course, uncertain to
lead to funding, and this, coupled with the perception of falling ‘success rates’, may be a considerable
21
disincentive for research groups and even an absolute barrier for most Southern research institutions,
at least to act as co-ordinators.
The procedures for application are complex. The instruments are multiple and eligibility criteria not
always easy to comprehend. Such procedures may contribute to difficulties in creating equitable
partnerships, as Southern partners have additional difficulties in understanding them, including access
to the website or phone. There are also concerns as to the level of allowable costs, and disbursement
schedules, given the changing nature of national research support.
Administrative reporting requirements, and the advance payments procedures, cost statements and
payments, which cause very long delays in money transfers are also criticised. Steps already taken,
such as the running of training workshops for co-ordinators, are to be commended but there may be
other areas in which dialogue between the INCO Directorate and researchers could be productive. A
regular meeting of involved researchers may provide a useful opportunity for discussion with the EC
over how such procedures can be improved.
Selection process
The selection process for projects involves two steps - scientific review and regional review. Some
respondents judge that the nature of the peer review process by experts leads to conformity in themes
and methods rather than innovation and relevance. Many people do not understand the role of the
regional panels and the basis on which they judge. However, most people accept that any such
selection processes have their inherent limitations, and judge the track record of STD and INCO-DEV
as being fair.
There is a view amongst researchers that there should be a two-stage process, as practised by other
research funders. This is seen as a way of reducing the heavy' burden of the current application
procedures. However the resource implications of this are seen as prohibitive by the EC. There is
also a process of pre-proposal checking within the EC for obtaining feedback on outline proposals
early within the application. There is however recognition within the EC that attention needs to be
given to making the overall application procedures less complex for applicants.
Capacity-building and Getting Research into Policy and Practice
There is a need to build up and strengthen the existing limited capacity in HSR. In the last decade,
health development in developing countries was retarded, not only due to financial and human
resource limitations, but also by limited capacity to produce their own policy.
Very few studies have been carried out regarding HSR capacity. One such assessment of HSR in
developing countries was conducted through a postal and web survey to 176 HSR institutions in
developing countries8. It concluded that HSR producers need to increase their capacity and build up a
critical mass to engage effectively in policy development as well as to absorb a larger volume of
resources. The relationship between funding and critical mass needs further research to identify the
best funding support, incentives and capacity-strengthening approaches.
There are differences in HSR experiences between regions which reflect their varying contexts. This
is well reflected in an Alliance report which points out, for example, the significant history of HSR
within the Latin American region and more recently its development in South East Asia.
In the above study of successes and failures of capacity-building of institutions different programmes
such as TDR, IHPP, and COHRED were analysed. This suggested a number of different strategies
8 Gonzalez-Block, M and Mills, A (2003)
22
including a general need for national mechanisms for institutionalisation of health systems research
including enabling dialogue with policy-makers.
The EC INCO-DEV programme has emphasised the importance of capacity-building and GRIPP.
This is, for example, reflected in its application process which includes explicit consideration of this.
However there are various aspects to capacity-building which call for more detailed and delineated
strategies. In particular capacity-building:
• has different implications for individuals and institutions
• needs to relate both to researchers’ ability to disseminate effectively and to the
policy-makers’ ability to use research
• needs to recognise the different needs of Southern and Northern institutions.
A major element of the EC INCO-DEV HSR programme has been mechanisms for collaboration
between researchers from the North and the South. This is supported by a main conclusion of a study
of the International Health Research Programme of the EC9.
It is important however to recognise that alongside the overall objectives of any programme in this
area, the specific project mechanisms deployed by any funder, including the EC, are key. Thus the
specific mechanisms such as priority-setting, application and reporting will all have implications for
capacity-building. There is, for example, within priority-setting criteria, a need to strike a balance
between short term project goals and long term HSR capacity-strengthening - for “sailing while
mending the boat”.
The recent phenomenon of international and national mobility of human resources is a major
emerging threat to the research community with both ‘push’ and ‘pull’ factors. A high turnover of
national health authorities has also resulted in the frequent “loss” of institutional memory and policy
makers who have been sensitised on HSR. There is a need to develop human resources, institutions,
and the research environment. A critical mass of researchers representing different disciplines such as
physicians, epidemiologists, health economists, bio-statisticians and social scientists needs to be
linked to visible institutions, since the HSR area needs good links between policy-makers, planners
and the institutional set-up. Communication and dissemination of results from researchers should
reach these people to foster a positive research climate enabling evidence-based policy-making.
Collaborative research networks could also play a role in research capacity-building and promoting
utilisation of research findings.
Tools to accomplish the above include allocation from national health expenditure as well as
earmarking a proportion of project funding from development agencies for research capacity
strengthening. Training of young professionals could employ a staggered (sandwich) model with
research carried out in their respective countries and course, with analysis outside to safeguard the
relevance of the research. Networking or twdnning of institutions (South-South or North-North)
would assist in building institutions. Grants for supporting returnee graduates enabling them to
maintain and further upgrade their competence will be of crucial importance. The maintenance of a
long-term perspective in these relationships will be equally important.
Producing and using research results is one of the major operational components of a national health
research system. However, the current weakness is that the research process and the policy process
tend to exist in different domains, with research often having limited impact on policy. Researchers
and decision-makers tend to interact only around the product of their processes which may be, for
example, the results of a study for the researcher and a set of priorities for the decision makers. More
attention needs to be given to establishing and maintaining ongoing links between these.
9 Guha-Sapir D (2002)
23
Many scholars defend a linear relationship on GRIPP, in which research automatically leads to
rational policies, but most argue that the relationship is more hazy. Even the best designed research
with clear results does not necessarily get translated into practice. The relationship between research
and health policy is rarely ‘rational’, but based on an interplay of personalities, context and political
expediency. Researchers and policymakers belong to overlapping communities of interest, which
sometimes work closely but at other times pursue separate paths. They have different concepts of
time. For policy-makers, timing is urgent and short term and public opinion is important.
Researchers often take a longer-term view and refer to a peer group who value political impartiality.
Research findings will therefore only reach policy agendas when various factors come together,
namely, when the solutions offered are considered feasible; when there is support for such solutions;
and when policy makers feel it is legitimate to take action.
There has been an over-simplification of getting research into policy and practice through the
strengthening of researchers’ communication skills. This is based on an assumption that proper
packaging would ensure the best use of research. There is a need to incorporate several other factors,
for example, the active participation by key stakeholders in the research planning process and the
involvement of researchers in the policy process, social marketing of research results to the general
public through an informed media10. This requires a national mechanism with a dynamic, interactive,
and inclusive process. Skill and understanding of the concepts and practices of knowledge
management for change are essential for this national mechanism.
Both governments and
international research community have major roles to play to stimulate research into action.
Health Systems Research System
In conclusion, this review of the EC support to HSR has focused on a series of different elements of
health systems research. It is important however that these are not viewed in isolation but as part of
an overall health research system". Changes to one part of the system are likely to result in effects
elsewhere. Any system includes explicit and implicit ‘carrots’ and ‘sticks’ which influence the
behaviour of the actors within the system. The EC has, through its recognition of the importance, not
only of the production of knowledge, but also of capacity and the GRIPP process, have made
important interventions in all parts of the research system. It is important that these interrelationships
are also recognised and better understood. Mexico will provide an important opportunity for this
process.
10 Chunharas, S (2000)
11 Pang, T, Sadana, R, Hanney. S et al (2003)
24
Guidelines for Proposal
Case study global public private partnerships in health
NOTE:
Please take into account that this proposal concerns only the realization of
the case study in your country I geographical area where the field research
will take place.
At this moment Wemos does not have resources to support other activities
like production of educational materials, promotional activities etc. In the
next workshop, in March - April 2004, we will discuss and decide about the
lobby and advocacy activities.
1. Introduction: (not longer than 1 'A
page)
- Short introduction of your organization:
•
•
•
•
Description of main objectives
Description of main activities
Structure of your organization
Geographic coverage of the activities of your organization
- How do GPPI's relate to the activities/objectives of your organization, and
why is this issue important for the work your organization is doing.
2.
Objectives:
What objectives is your organization aiming to achieve by carrying out this
case study?
3.
Expected results and indicators:
Results you expect to have obtained after completion of the case-study. For
each result formulate indicators, when possible, to measure if you have
obtained these results.
4.
Planned activities:
Describe the activities that you have planned in order to prepare and carry
out the case study and add a time frame according to the planning agreed in
the workshop (end of May in The Netherlands)
e.g.
•
•
•
•
Definition of geographic areas;
Hiring a consultant / extra personnel; defining functions ;
Interviews with health authorities
Interviews with local groups and leaders, etc.
5. Budget
Please use the planned activities for the estimation of it, e.g.
• Travel expenses
• Consultancies
• Materials
• Extra office costs
NOTE:
The budget can not exceed Euro 5.000 for the period between July 2003
and July 2004, this amount does not include travel and accommodation
costs related to the workshop that will take place in Kenya in March - April
2004.
THE PARTNERSHIP
M O World Health
Organization
For Maternal, Newborn & Child Health
EXECUTIVE SUMMARY
Newly-formed global health partnership aims to harmonize and intensify actions at country, regional and
global levels in support of the Millennium Development Goals for maternal and child health.
Why a new global health partnership for
maternal, newborn and child health?
What does the Partnership
Newborn & Child Health offer?
Each year, more than half a million women die in
pregnancy or childbirth, and more than 10 million
children die before their fifth birthday, almost
40% in the first month of life. Recent research
finds that at least two-thirds of these deaths
could be prevented with proven, cost-effective
(interventions that could and should be available
'to every woman and child today. By expanding
access to these interventions and integrating
maternal, newborn and child health efforts, an
estimated 7 million deaths of women and
children could be prevented each year. Given
the scope of this challenge, no individual
country, organization, or agency can address it
alone.
The Partnership provides a forum through which
members can combine their strengths and implement
solutions that no one partner could achieve alone. The
Partnership supports country-led efforts towards
universal coverage of essential interventions for
maternal, newborn and child health by focusing on the
following:
for
Maternal,
• Country Support - actively promoting improved
partner coordination in countries and supporting the
creation, implementation and evaluation of a single
national plan.
• Advocacy - raising the profile of maternal, newborn
and child health on political agendas and advocating
for increased resources - financial and other.
What is the Partnership for Maternal,
Newborn & Child Health?
• Effective interventions — promoting the assessment,
scaling up, and delivery of evidence-based, costeffective interventions, with a focus on reducing
inequities in access to care.
The Partnership for Maternal, Newborn & Child
Health is a new global health partnership
launched in September 2005 to accelerate
efforts
towards
achieving
Millennium
Development Goals (MDGs) 4 and 5. This new
partnership is the result of a merger of three
existing partnerships: the Partnership for Safe
Motherhood and Newborn Health, the Child
^Survival Partnership and the Healthy Newborn
'Partnership. The Partnership aim is to intensify
and harmonize national, regional and global
action to improve maternal, newborn and child
health.
• Monitoring and evaluation - assessing progress by
holding stakeholders at all levels accountable in
meeting their financial and policy commitments.
How can we get involved?
The Partnership for Maternal, Newborn & Child Health
welcomes new members. To learn more about the
Partnership's activities and how you can become
involved, please contact us.
Who is in the Partnership for Maternal,
Newborn & Child Health?
The Partnership joins together the maternal,
newborn
and
child
health
communities,
encouraging unified and effective approaches
that promise greater progress than in the past.
The Partnership is made up of a broad
constituency of more than 80 members
representing
partner
countries,
UN
and
multilateral
agencies,
nongovernmental
organizations, health professional associations,
bilateral donors and foundations, and academic
and research institutions.
r •
1
. F
1211 Geneva 27 - Switzerland - Tel.:+4122 791 49 14 - Fax:+4122 791 41 71 - email: info@pmnch.org
www.pmnch.org
RESUMEN PARA LA ACCION
Una alianza para la salud, de reciente constitucion, aspira a armonizar e intensificar las actividades en los
pianos nacional, regional y mondial de apoyo de los Objetivos de Desarrollo para el Milenio relatives a la
salud de la madre y el nino.
<i,Por que fundar una nueva alianza
mondial para la salud de la madre, el
recien nacido y el nino?
Cada aho mas de medio milion de mujeres
mueren durante el embarazo o el parto y mas de
10 millones de ninos mueren antes de cumplir
los cinco anos, casi el 40% durante el primer
mes de vida. Investigaciones recientes han
comprobado que por Io menos dos terceras
partes de estos fallecimientos podrian evitarse
con intervenciones probadas y eficaces en
funcion de los costos que podrian y deberian
estar a disposicion hoy en dia de cada mujer y
cada nino. Cada aho podria evitarse una cifra
estimada de 7 millones de fallecimientos de
mujeres y ninos si se ampliara el acceso a estas
intervenciones y se integraran los esfuerzos en
favor de la salud de la madre, el recien nacido y
el nino. Habida cuenta de la magnitud de este
desafio, ningun pals, organizacion u organismo
puede por si solo responder adecuadamente.
i,Que es la Alianza para la Salud de la
Madre, el Recien Nacido y el Nino?
La Alianza para la Salud de la Madre, el Recien
Nacido y el Nino es una nueva alianza mundial
de salud fundada en septiembre de 2005 para
acelerar las iniciativas encaminadas a lograr los
Objetivos de Desarrollo del Milenio numeros 4 y
5. La nueva alianza es consecuencia de la
fusion de tres asociaciones existentes: Alianza
en favor de la Maternidad sin Riesgos y de la
Salud del Recien Nacido, la Alianza para la
Supervivencia del Nino y la Alianza para la
Salud del Recien Nacido: El objetivo de la
Alianza es intensificar y armonizar las iniciativas
nacionales,
regionales
y
mundiales
encaminadas a mejorar la salud de la madre, el
recien nacido y el nino.
i,Quien participa en la Alianza para la
Salud de la Madre, el Recien Nacido y el
Nino?
La Alianza enlaza las comunidades que se
ocupan de la salud de la madre, el recien nacido
y el nino, promoviendo enfoques unificados y
eficaces que prometen progresos superiores a
los de antes. La Alianza esta formada por un grupo
amplio de mas de 80 miembros que representan a
paises miembros, organismos de las Naciones Unidas
y organismos multilaterales, organizaciones no
gubernamentales, asociaciones profesionales de la
salud,
donantes
bilaterales y fundaciones e
instituciones academicas y cientificas.
<j_Que ofrece la Alianza para la Salud de la
Madre, el Recien Nacido y el Nino?
La Alianza ofrece un foro en el cual los miembros
pueden combiner sus
puntos fuertes y aplicar
soluciones que ningun participante podria conseguir
por si mismo. La Alianza apoya las iniciativas de los
paises para conseguir una cobertura universal de las
intervenciones esenciales para la salud de la madre, el
recien nacido y el nino, centrandose para ello en Io
siguiente:
• Apoyo de los paises: - promover activamente una
mejor coordination de los miembros en los paises y
apoyar la creation, ejecucion y evaluation de un
plan nacional amplio para la salud de la madre, el
recien nacido y el nino.
• Promotion - elevar el perfil de la salud de la
madre, el recien nacido y el nino en los programas
politicos y defender la asignacion de mayores
recursos, financieros y de otro indole.
• Intervenciones especificas: - promover la
evaluation,
ampliation
y
realization
de
intervenciones basadas en los hechos y eficaces en
funcion de los costos a favor de los servicios de
salud de la madre, el recien nacido y el nino,
centrando el interes en reducir las desigualdades del
acceso a la atencion.
• Vigilancia y evaluation - evaluar los progresos
realizados estudiando periddicamente el acceso a
los servicios de salud de la madre, el recien nacido y
el nino y haciendo a los participantes en todos los
niveles responsables de que han cumplido sus
compromisos financieros y politicos.
<i,C6mo puedo contribuir?
La Alianza para la Salud de la Madre, el Recien
Nacido y el Nino da la bienvenida a nuevos miembros.
Para conocer mejor las actividades de la Alianza y
como participar en ella pongase por favor en contacto
con:
1211 Geneva 27 - Switzerland - Tel.:+4122 791 49 14 - Fax:+4122 791 41 71 - email: info@pmnch.org
www.pmnch.org
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