What future for those PPPs?

Public-private partnerships need integration

SUMMARY
Public private partnerships have made a dramatic impact on research for developing country diseases, but it’s time to take them in for service. RealHealthNews advisor Kent Buse believes they should integrate their work with developing countries’ own planning, priorities and health services – just as donors are promising with the International Health Partnership. If they are serious about health, they also need to think about non-communicable diseases and health promotion – and consider alternatives to private finance.

Repent of seven sins, reform, and submit to independent monitoring – that’s the best future for the multitude of public private partnerships in health, such as the Medicines for Malaria Venture, the Alliance for Microbicide Development and 21 others, according to Kent Buse and Andrew Harmer of the UK-based development think-tank, the Overseas Development Institute.

In a paper published earlier this year, Buse and Harmer looked at the governing boards of over 100 ‘global health partnerships’, and found only 23 met their criteria of having representatives from both public and private sectors on their decision-making bodies – a “surprising finding” in itself, say the authors. They then analysed the performance of the 23, and while recognizing their many virtues, concluded that seven misdeeds were holding them back.

These misdeeds were “skewing national priorities by imposing external ones; depriving specific stakeholders a voice in decision-making; inadequate governance practices; misguided assumptions about the efficiency of the public and private sectors; insufficient resources to implement partnership activities and pay for alliance costs; wasting resources through inadequate use of recipient country systems and poor harmonization; and inappropriate incentives for staff engaging in partnerships”.

Alana Conner Snibbe, writing for the Stanford Social Innovation Review, Spring 2007, interviewed Buse on the analysis. “The large foundations that have been involved in developing these partnerships have not been sensitive to the wider discourse on development effectiveness… Instead, they are mainly concerned with getting results and getting them quickly, to prove to their donors their effectiveness.”

“Global health partnerships arose because people believed that [national health systems] are buggered” Buse explained to Snibbe. “And so they work outside of the systems. But not using the national systems sucks resources away from them.”

Although global health partnerships can create “islands of excellence” by sidestepping national systems and focusing on one problem in one place, he told Snibbe, “it makes the sea a lot less hospitable for other public health interventions”.

To help correct these problems Buse and Harmer propose that “a simple assessment mechanism be devised, to score such partnerships on a biennial basis on their performance across a range of indicators. The resulting assessment might aid investors (particularly donors and foundations) make decisions on supporting [the partnerships]. It might also provide reform-oriented partners ammunition to deal with recalcitrant partners, secretariats or hosts”. And they recommend the Centre for Global Development’s ‘Commitment to Development Index,’ which assesses rich nations on their aid performance, as useful model for the assessment.

So RealHealthNews wrote to Buse, to ask him to go into a little more detail. How could such partnerships – which he and Harmer call ‘Global Health Partnerships’ or GHPs - really be ‘measured’?

“Donors and foundations are very much interested in getting value for money from and improving the performance of GHPs” Buse replied. “To date, however, this has taken the form of some broad evaluations of specific partnerships and across the GHP landscape (for example work by McKinsey and Karen Caines), as well as commissioning the development of some metrics to assess the performance, particularly of product development partnerships – for example those done by the Pharmaceutical R&D Policy Project and Boston Consulting Group.

“These metrics are, however, too narrow in their purview (that is they look only at R&D partnerships) and too narrow in their scope in that they fail to address some key governance and other issues.

“Take, for example, the metric developed by Pharmaceutical R&D Policy Project (PRPP). While Mary Moran’s group is ultimately interested in ‘health value’ from these investments – and measure this value according to some extremely important parameters, such as safety, efficacy, suitability and affordability of drugs for developing countries – their metric is specifically designed to improve and expedite the drug development process. They acknowledge that their framework does not accommodate ‘downstream’ concerns about relevance, delivery infrastructure, or human resource capacity or capacity building. We would argue that this narrow approach has its costs.

“Fairlamb’s evaluation of the Medicines for Malaria Venture, for example, suggested that greater input from southern constituencies may have saved some of the fruitless investment in the Venture’s first drug to reach Phase Three only to be terminated.

“Yet more broadly, what is the point of expending time and effort in developing new drugs if, ultimately, they cannot be delivered to the people who need them? There is obvious ‘health value’ here too, and a broader metric is required that takes them into account.

“Again, going back to PRPP, its metric does not incorporate important governance issues – for example, those concerning partners’ social responsibilities and suitability for partnering. PRPP’s focus on incentives for the private sector to partner means that its performance metric understates the ‘health value’ that accrues from a private sector that takes its public responsibilities seriously.

“It is not enough, as PRPP does, to simply list the various stated motivations behind a drug company’s desire to partner and make passing reference to corporate social responsibility (CSR); rather, a robust measure of a company’s actual CSR should be at the heart of a partnership performance metric.

“A related governance consideration is that of representation on governing bodies. That a GHP should be representative of its different stakeholders would strike most people as being self-evident, and yet R&D GHPs score poorly on adequate representation at Board level of representatives from developing country representatives. Two of the five partnerships PRPP group review – the TB Alliance and Institute for One World Health– have no representatives from individuals working at institutions based in the global South on their Boards. So, broader metrics are clearly required.

“Most importantly, existing performance metrics are not applied in an ongoing, consistent and systematic way. Our message to health ministers is that, given the significant investment in these new initiatives, partnership-specific evaluations and narrow metrics may be important, but fail to deliver what is ultimately required - a new performance evaluation metric which can be applied across the field and is regularly undertaken and upon which decisions to improve partnership performance and partnership funding can be made.”

RealHealthNews remarked that donors are becoming increasingly keen to think in terms of health system support, as so many initiatives run into the sand when they get to country level. So, we asked, won't this soon be true of most GHPs, when they generate products but can't get them delivered?

“Absolutely!” replied Buse. “When lack of access to essential medicines hovers around 30%, and in Africa is as high as 50%, one has to question the disproportionate investment in product development.

“Take the case of congenital syphilis: Schmid and colleagues at WHO have estimated that the global burden of congenital syphilis is close to half a million infected infants a year, close to the burden of mother-to-child HIV. Syphilis, however, receives almost no attention from the international health community.

“There have been policies to address congenital syphilis in most developing countries for decades, the diagnostic has been widely available for years, and treatment is with penicillin (a drug which is on the essential medicines list of every country).

“However, despite this, the burden of congenital syphilis continues to result in infected infants, stillborn babies, women suffering miscarriages, all over the world.

“The problem is not the lack of a product to intervene and prevent these outcomes, it is the lack of health system capacity and political commitment to invest in it to deliver existing products.

“Most GHPs are very ‘Gates heavy’, by which I mean the bulk of funding for many of these initiatives is provided by this one philanthropic organization, the Bill and Melinda Gates Foundation. Traditionally the Foundation has focused on techno-fixes and magic bullets, but it is encouraging that they are now beginning to support supporting some access initiatives and health systems strengthening.

“Nonetheless, political support for systems development will need to come from other quarters, particularly like-minded donors, civil society, academia and ministers of health – some of whom have seats on some of the GHP Boards. In this respect, the newly launched International Health Partnership may well be a step in the right direction, in that it reiterates commitment to systems strengthening and other good aid and development practices. Yet the devil will be in the yet to be defined detail of the accountability mechanisms that are put in place to ensure that action reflects ambition.”

So, asked RealHealthNews, what about an extra, over-arching GHP, one for health systems, that would stimulate health system growth but by its nature embrace and monitor the other disease-specific GHPs?

“Andrew Harmer and I very much agree that there is a need to link the reporting of a monitoring mechanism to some institutionalized platform for a proper discussion – both of the results of the assessments as well as the bigger picture issues to which you refer” replied Buse.

“The platform would need to allow for a frank exchange of ideas and provide some purchase in terms of bringing about change. Different configurations of what this platform might look are conceivable, but I don’t think that it ought to be a new GHP.

“We could link it to the OECD Development Assistance Committee (DAC) where discussions on donor performance take place – and at which a high level forum proposed a set of six principles concerning partnership alignment and harmonization.

“I don’t think this idea has been floated at the DAC and it is possible that the Committee might have been more interested in a one-off process to bring GHPs into line with existing best practice on alignment and harmonization than take on GHP performance per se. And although the Committee can convene high level delegates – particularly among bilaterals – it is likely that some relevant stakeholders would not find this a suitable venue.

“Alternatively, we could establish a global health partnerships summit – where staff and board members of various partnerships could respond to the assessment report and make commitments for progress and, importantly, coordinate their actions with other partnerships and donors. One could envision such a summit taking place on the margins of the World Health Assembly, for example.

More generally, responded RealHealthNews, aren't we coming full circle here? That is to say that the functions that will be required of any monitoring body will be public health functions - involving more stakeholders, creating harmony among the GHPs, taking the broad view - and it looks like a turn of the wheel back to a global health organization. Isn't this a new WHO assembled from parts? 

“Yes, the question of monitoring and reporting on partnerships and linking this to resource allocation across global health problems brings us to the vexing problem of global health governance – or shall we say lack thereof” replied Buse. “Some people are calling for a ‘World Health Assembly plus” (i.e. involving both WHO and civil society), yet as experience with UNAIDS reveals, such an arrangement does not guarantee perfect governance of the global AIDS response and in particular harmony or even coordination among the global players. A summit which convenes partnership decision makers, donors and civil society may be the most we can aim for to monitor and coordinate action.

“WHO is a publicly accountable institution and therefore is amenable to public pressure. If we want a WHO that, for example, champions human rights, is adequately funded, retains its authority, is grounded in an ethos of social justice etc, then we have to make sure that these priorities prevail. The Director General, Margaret Chan, has stated her commitment to a rights-based approach to health: it is up to us to make sure she holds good to her promise. Yet one can not imagine that the WHA can be reformed in the foreseeable future to provide a platform for meaningful discussion and decision-making on GHPs.”

What of the partnerships you and your colleague left out, asked RealHealthNews, because they didn't fulfil your criteria? If you included some by widening the criteria - e.g. on requiring governance to include a private sector body - have you any reasonable idea of how many more "quasi-GHPs" would enter the list, and any rough idea on how they might alter your conclusions?

“Our principal criteria of what constitutes a GHP – which one would have thought obvious in analyzing public-private partnerships but one which many other analysts do not use – is a formally shared responsibility between the public and for-profit sector in decision making. By formal, we mean representation on a governing body. Of course, this does not mean that if the private sector is not represented on the board that it can not or does not find other means of influence – through the technical committees for example.

“But in relation to your question, if we widened our criteria of what constitutes a global public private health partnership, I think that our findings would remain relevant to the other 70/80 quasi-GHPs which were identified on the database of the now defunct Initiative on Public-Private Partnerships for Health (IPPPH) – but that is an empirical question which I can not answer with certainty. The main point is that all these partnerships should be subject to systematic and ongoing performance-monitoring metric as we discussed earlier.

“Beyond the performance metric that is required and system to coordinate action on its findings, our other critical message for health ministers that they begin to think about how they can best stimulate GHPs in the area of non-communicable diseases (NCDs).

“This is especially important when you consider that 80% of the burden of NCDs occur in the developing world. In the area of NCDs, partnerships could more readily address the societal or structural determinants of poor health and perhaps make an even greater contribution than is presently being made by the communicable disease GHPs to bring about better health in the epidemiological transition.”

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