|Keywords:||Biotechnology programmes/networks, Health, Drugs, Vaccines, Private industry, public institute, United Nations, WHO.|
|Correct citation:||Walt, G. and Lush, L. (2001), "Getting drugs to where they are needed: Global public private partnerships for neglected diseases." Biotechnology and Development Monitor, No. 46, p. 9-12.|
To an increasing extend the research, development and delivery of drugs for neglected diseases is undertaken by Public Private Partnerships. Concerns are being raised about their key characteristics, like the inequality of the partners or their relationship with international organizations. This article analyses the impacts at country level, such as additional cost and workload through one-to-one negotiations between the initiatives and the countries, to the demands on the existing health systems. It also assesses the increasing inequalities within and between countries.
One of the new mechanisms for getting drugs for neglected diseases to low and middle income countries is through global Public Private Partnerships (PPPs, see box by Lehmann) or joint public-private initiatives. They are a new form of governance, which bear closer scrutiny. Because in the health sector they are so new, almost all the focus has been on the global level, on how partnerships are established and how goals and rules of engagement are agreed upon. Very little focus has been on how the actions of the partnership will impact on the country concerned, partly because they are new and not much has yet happened at the country level. Also recipients have been only marginally involved in their establishment.
Global Public Private Partnerships (GPPPs) are part of a new set of governance mechanisms that are moving away from hierarchical, vertical, inter-governmental institutions such as the World Health Organization (WHO), with its constituency of member states, towards horizontal, participative, coordinating arrangements between private philanthropic organizations, companies, public research institutes and others. GPPPs can be described as "a specific form of governance, a mechanism of mobilizing political resources in situations where those resources are widely dispersed between private and public actors." As with many new mechanisms, they are difficult to define, and a number of different typologies have been promoted.
There are a number of initiatives that address the issue of drugs for neglected diseases. On the one hand, product development GPPPs seek new drugs or vaccines, especially for tuberculosis (TB), malaria and Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS). On the other hand GPPPs are used as a mechanism to improve poor countries' access to drugs. Merck's donation since 1989 of mectizan for onchocerchiasis (river blindness) is the oldest of the GPPPs and the most sustainable, given Merck's promise to continue providing free drugs while the disease exists. Others include the UNAIDS initiative, Accelerating Access to HIV Care, Support and Treatment, which negotiates with pharmaceutical companies to get preferential prices for anti-retroviral AIDS drugs for some countries (see box). These GPPPs may be embedded in a United Nations (UN) organization, which provides the secretariat, or they may be a self-standing entity with a small secretariat.
|Accelerating Access to HIV Care, Support and Treatment
The Joint United Nations Programme on HIV/AIDS (UNAIDS) is a partnership of seven UN agencies and donors, formed in 1996 to coordinate global HIV/AIDS programmes. Within its secretariat in Geneva, it hosts a Global Public Private Partnership (GPPP) entitled Accelerating Access to HIV Care, Support and Treatment.
This partnership was formed in 1998 between UNAIDS and five pharmaceutical companies (Boehringer Ingelheim (Germany) Bristol-Myers Squibb (USA), GlaxoSmithKline (USA), F. Hoffman-La Roche (Switzerland), and Merck (USA)). It provides advocacy and policy guidance on HIV care at global level as well as 'fast track' support for countries that wish to expand access to HIV/AIDS care, support and treatment, including anti-retroviral drugs for AIDS.
UNAIDS assists countries to identify care options and potential suppliers of diagnostics and treatments. It also supports efforts to reduce prices, including negotiations with the five companies in the partnership, open competition including generic drugs and cancellation of import taxes on drugs. In 2000, it started to develop an international database of drugs prices and sources in collaboration with the non-governmental organization Médecins Sans Frontières (Doctors without borders, MSF). A large number of countries in Africa and Asia have individually applied to this partnership for support, but rather little has been achieved in practise. In addition, until the recent international furore over anti-retroviral drug prices, this partnership did not succeed in dramatically reducing quoted prices for drugs.
One of the key characteristics of these new governance mechanisms is that they are made up of a number of different 'partners', which may be multi- or bilateral agencies, non-governmental organizations (NGOs), industry, or foundations. The pharmaceutical industry is often assiduously wooed to join such partnerships. While some GPPPs include developing country representation, they do not all have partners from the South. This means that the targeted recipients of such partnerships are often not involved in formulating policies, discussing priorities or considering the problems around delivery. From the little experience to date a number of concerns have been voiced regarding these partnerships.
First, many regard the term 'partnership' or even 'partner' to be a misnomer. Many NGOs in particular argue that the words divert attention from the fact that power relations are asymmetrical. 'Partners' may or may not be donors to the partnership, they are not equal, and the goals and values of partners may differ. It seems more valid to see such groups as networks instead of partnerships, or as "loose alliances of governmental agencies, international organizations, corporations, and elements of civil society [... ] that join together to achieve what none can accomplish on its own" (Reinicke 1999). However, even this term is unsatisfactory and may underestimate the extent to which GPPPs may be legal, long-lived entities with a core decision-making structure. For the sake of continuity we will go on using 'global public private partnerships' while acknowledging the need for a great deal more information about the different forms of governance and practice.
Second, there has been considerable optimistic investment of time and energy in GPPPs, which is not matched by knowledge of processes or practice. Reinicke for example, talks of them as overcoming 'democratic deficit' because they include so many different interests. However, at least in the health sector, developing countries, which are often the beneficiaries of such networks, tend to be marginalized. Also, while all GPPPs include representatives from the NGO community, there is considerable dissent over who they represent. There is little evidence to show that NGO partners share the same values, or even a common discourse, or that they represent more than a tiny proportion of civil society somewhere in the world.
Furthermore, agencies often have multiple memberships of partnerships, and as they rush from one GPPP meeting to another, it is doubtful whether they are able to participate fully. Few of the new partnerships are as transparent and open as the Global Alliance for Vaccines and Immunization (GAVI), which has several layers and opportunities for participation at country, regional and international levels. In most partnerships, decision-making may in fact be in the hands of a relatively small group of partners.
Third, many have questioned the accountability of GPPPs. Are they accountable to their own structures (boards, funds, councils), or to their constituencies (governments, shareholders, member states, beneficiaries)? Small secretariats that are typical of global partnerships may hold significant power because they control agendas and implementation. 'Partners' who may be participating in several GPPPs have large burdens in terms of attending meetings and reading papers, so may not always be able to make informed judgements on all issues.
Fourth, GPPPs are perceived to be complementary to the traditional public policy institutions such as WHO and are not expected to replace them, but there are questions as to how far they undermine such institutions. For example, it is not clear how far they may be duplicating activities. For malaria alone there are several partnerships: Roll Back Malaria (a coordinating partnership based at WHO), the Medicines for Malaria Venture, Malarone Donation Programme, and LAPDAP, among others. It is also unclear how stable or sustainable GPPPs are in comparison with traditional hierarchies such as WHO. They may for example only have funding for up to five years. Some are particularly dependent on one source such as the Bill & Melinda Gates Foundation . There is little experience on how such networks will be sustained or transformed if they are successful or terminated if goals are not met.
Finally, many GPPPs focus on particular problems and narrow issues. Three diseases have dominated global discourse over the past couple of years: AIDS, TB and malaria. These diseases are considered threats to the high-income world as well as to low and middle-income countries. Huge efforts and resources are being put into them. The campaign to lower the prices of AIDS drugs, and the proposed Global Fund for Health to be announced at the G8 talks in July 2001 in Genoa, are examples of such initiatives. Observers are concerned that preventive measures, which are particularly important with HIV/AIDS as well as a host of other important diseases, are being neglected. For example, diarrhoeal diseases are still a major killer of children in poor countries.
None of these questions mean that GPPPs are necessarily a bad thing, but the whole discourse is taking place at the international or global level. People are only just becoming aware of the existence of GPPP networks. Nowhere is this more so than in developing countries, the potential beneficiaries.
From the country perspective, there are huge gains and looming difficulties in dealing with GPPPs, in terms of transaction and opportunity costs, system demands and inequalitiesAdditional costs for developing countries are likely to arise for a number of reasons. They can consist of transaction costs of deciding, planning, and organizing the action to be taken when two or more parties do business; the cost of changing plans and the cost of ensuring the two parties comply. There are also opportunity costs, those costs incurred by giving up the opportunity to do something else.
The various GPPPs negotiate on a one-to-one basis between the initiative and receiving country. This creates burdens on countries in terms of proposals or applications for each health initiative, information collection, monitoring or meeting missions. While GPPPs are aware of this additional demand, they need to satisfy their own boards and donors, and therefore have to have a process of monitoring and guaranteeing outcomes from their support. Experience suggests that where the commercial sector is involved, it may also demand additional, special monitoring arrangements.
On top of such demands, there are already huge demands on public officials in many developing countries. For example, government officials may well be taking part in planning exercises to qualify for World Bank debt relief, the Poverty Reduction Strategy Papers (PRSPs). This exercise has considerable value to a country, as it allows funds that would normally be used to pay back debts to be allocated to the social sectors. However, the process of drawing up PRSPs and consulting widely means that reaching completion takes considerable time and energy. Furthermore, ministry officials might well be expected to be taking the lead in Sector-Wide Approach Programmes (SWAPs). The idea is that instead of each donor providing project aid to its own project with its own financing, monitoring and evaluation system, donors pool their funds under a SWAP, and the government decides what the money should be spend on after having drawn a national health plan. There should then be one simpler system for all donors rather than different ones for each donor. SWAPs have been introduced in 19 out of 22 Sub-Saharan countries. However, not all donors are willing to join them. Health ministries may therefore still have to negotiate with individual donors as well as with those within the SWAP.
All these demands are occurring in a context of health reforms and are often donor-led. The necessary health reforms are contested, take time to implement, and are often initiated in a context of considerable staff demoralization and poor pay. In such situations, valued new drugs arriving through channels like GPPPs may well leak into the private sector or be subject to informal exchanges.
System demands may also create major problems.
Finally, there are major concerns about increasing inequalities both within and among countries.
The debate about getting antiretrovirals to all those who need them is well rehearsed. In those countries which have GPPPs to provide cheaper antiretroviral drugs, only a minority of people with AIDS will receive the drugs. Even in Brazil, where such drugs are free, many people in rural areas do not have access to them. In Senegal, a system for selecting patients by committee has been established. In most other African countries which have agreements to receive cheaper drugs, they are available only in the private sector, to those who can afford to pay. While those who can afford to pay should not be denied access to these drugs at much cheaper rates, they represent a minority in most countries.
GPPPs, understandably, are likely to select countries they feel will demonstrate a fair level of success, and such countries are likely to be the most politically stable, least populated, but not necessarily the most needy. Qualifying conditions for GAVI, for example, seem to be most difficult for the least-organized, least stable countries and their populations may lose out. Out of 74 of the poorest countries in the world eligible for assistance (with GDP per capita of less than US$1000), by May 2001 only 25 had been successful in getting vaccines and/or health systems support.
We are witnessing a burgeoning number of public-private entities, established to address particular problems. Many are supply-driven, for example, by donations from the pharmaceutical industry, and for reasons which range from a shift to greater corporate social responsibility or image building to market penetration. Such donations represent a very small part of industry's output and sales. Other GPPPs are demand-driven, and are largely initiated by the public sector, to overcome market failure in developing countries, for reasons which range from professional concern and public health ethos to fears of cross-border contamination of the population by infectious diseases. Industry participation in these entities is, so far, relatively minor.
The links between public and private sectors are necessary and to be encouraged. However, to ensure that goodwill and enthusiasm is not dissipated two main points need to be taken into account.
Too many GPPPs will lead to fragmentation and will not be sustainable.
It is essential to strengthen and to build up the health sector, so that health systems will be able to deliver new tools such as new vaccines and drugs. But in order to build up health systems, painstaking and consultative processes are needed to ensure effective implementation in developing countries. It will not be sufficient to get Ministers of Health on board. Health workers and their managers at the district level will have to be consulted and included in the process of improving health service delivery. Almost all drugs and vaccines have to be delivered through services, and this is where effort is essential.
Gill Walt* & Louisiana Lush**
London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK.
Phone +44-20-7927.2388, Fax +44-20-7637.5391
* E-mail email@example.com
** E-mail firstname.lastname@example.org
Borzel, T.A. (1998), "Organizing Babylon - on the different conceptions of policy networks" Public Administration, Vol. 76, pp. 253-273.
Buse K. and Walt G. (2000), "Global Public-private partnerships: Part II - what are the health issues for global governance?" Bulletin of the World Health Organisation, Vol. 78, pp. 699-708.
Lush L. (forthcoming 2001), "Editorial: International effort for anti-retrovirals: a storm in a teacup?" Tropical Medicine and International Health.
Reinicke W.H. (1999), "The other world wide web: global public policy networks" Foreign Policy, Winter 1999/2000, pp. 44-57.
UNAIDS (2000), Report of the Meeting on the Evaluation of the UNAIDS HIV Drug Access Initiative. Geneva, Switzerland, UNAIDS. http://www.unaids.org
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