Published on 5 August 2024
PSE in Health Cooperation - webinars series
In 2021, the SDC Health Network organized a series of webinars on private Sector Engagement in Health Cooperation, to explore the different forms of private sector engagement in health, and discuss challenges and opportunities in public-private partnerships.
In alignment with Switzerland’s International Cooperation Strategy 2021-24 and the Agenda 2030’s orientation towards fostering public-private partnerships (SDG 17), the SDC recently published a Handbook on Private Sector Engagement.
In this context, the SDC Health Network organised a series of webinars between March and September 2021 to explore the different forms of private sector engagement in health and to discuss the challenges and opportunities in public-private partnerships.
witzerland's International Cooperation Strategy 2021–24 aims to expand cooperation with the private sector and exploit its potential to promote sustainable development in low and middle-income countries, including in fragile and conflict-affected settings. To this effect, private sector engagement (PSE) is not a goal in itself, but a means to fulfil the Sustainable Development Goals (SDGs). The SDC has already accumulated substantial experience, particularly at the global level, to engage with the private sector in a targeted manner, in order to jointly contribute to the achievement of the SDGs. Interesting initiatives are also being promoted in selected countries through a variety of SDC instruments, both as short-term humanitarian interventions and longer-haul endeavours. In February 2021, the SDC published a Handbook on Private Sector Engagement, which provides operational guidance on the specific modality of Private Sector Engagement.
In health cooperation, the private sector “refers to all non-state actors involved in health: profit and not-for-profit, formal and informal, domestic and international. Almost all countries have mixed health systems" (Bull World Health Organ 2019; 97:434–435). The private sector plays a major role in all areas of healthcare provision including direct service delivery, production of drugs and commodities and related supply chain and key support functions, such as finance, transportation, and information technology services. Therefore, the path towards achieving the SGDs cannot ignore the private sector.
The Agenda 2030 sets out clear orientations for greater partnership (SDG 17), and encourages governments to identify common interests to foster new partnerships for universal health coverage (UHC), including with the private sector. To reach the agenda's objectives, the international community needs to find ways to effectively harness both the public and private sectors. This implies that traditional donors, such as SDC, also engage in efforts to better understand the private sector and to collaborate in an effective manner to maximize social returns.
Each module will last 1.30 to 2 hours. We will invite experts, partners and SDC colleagues to share their knowledge and experiences to help us navigate through current topical debates, global priorities, partnership modalities recommendations and a lot more. In a closing event (reserved for SDC staff) in October, we will analyze and think together on existing modalities and their applicability SDC's work. The module dates and programme might change according to external experts' availabilities.
Two weeks prior to each module, a detailed program will be shared to Network members per email and posted on this website. All webinars will take place on Webex.
Modules
As an introduction to the topic, the first event of this webinar series offered a 360° view on private sector engagement (PSE) in health cooperation. Guest speakers from different fields shared insights and their experiences in global frameworks and multilateral instruments to promote partnerships, engagement with the private sector in a humanitarian context, as well as opportunities and challenges that shape the private-public partnership landscape along the health sector value chain
Summary
This first session highlighted that more efforts are yet to be invested in rethinking private-public partnerships to shift towards a conceptualisation of PSE as a collective effort between a diversity of stakeholders and resources to improving global health. The presentations and the following discussion showed that frameworks to promote partnerships are already in development, with growing opportunities, for both governments and the private sector to move beyond the classic public vs. private dichotomy. Existing challenges and gaps were also identified. For example, developing regulatory frameworks has been hindered by disagreements around which are the suitable mechanisms for engagement. Matching the best fit models with the need for a collective standardised approach has also proven to be difficult. Partnerships driven by market forces are largely opportunistic and tend to develop at a speed that is hardly compatible with multilateral practice. And last but not least, mistrust and prejudice prevail between both sides.
Key Messages
- Productive partnerships with the private sector cannot be created in the middle of a crisis, trust and constructive dialogue need to be cultivated over time
- The unexpected necessities emerging from the COVID-19 crisis have nevertheless forced both the public and the private sectors to creatively engage with one another
- Documentation about successful stories of PSE lie in anecdotal evidence; strategies to harness it need to be identified
- Public sector cannot continue to promote PSE in the absence of the private sector around the negotiation table. Mixed health systems require new forms of governance
- Generating profit is essential to increase health sector financing: finding a win-win balance between profit and social returns is the key challenge
This second event deep-dived into pro-poor health markets and the role of local businesses. The key objective of this webinar was to rethink the nature and role of the private sector in mixed health systems. This entailed departing from the association of private actors as exclusively profit-seeking sharks, multinational corporations or Swiss businesses only. Instead, guest speakers illustrated the diversity and comparative advantage of for-profit actors engaged in health and their importance in local contexts based on their experiences in Bangladesh, Tanzania, Bosnia and Herzegovina, and Somalia.
Summary
Discussions with the panellists and the audience debunked some common misconceptions in pro-poor health market development and highlighted the importance of better communication and trust-building in private sector engagement. The concept of «mass market», as introduced during the keynote speech, strengthens the role of the majority of poor people as an economically active segment of the population, rather than a passive group of recipients. End-users are willing to pay for quality health products and services, and have the right to choose what they consider of best value for their money. Public health policies should learn to differentiate between poor market players and «have-nots», as well as design health financing and strategic purchasing approaches accordingly. If properly regulated and coordinated, private providers can enable better access and cover a wider range of needs, thereby complementing the efforts of the public sector. Successful public-private partnerships start from the mutual recognition of valuable comparative advantages and from the belief in a common goal.
Key messages
- Recognising the complementary roles of private and public actors is crucial.
- People’s needs exceed by far the capacity of any single sector to respond, hence collaboration between public and private health system components is inevitable.
- Effective PSE can only work in partnerships with common objectives and visions. Trust and common understanding between actors are necessary, already prior to starting to engage with one another.
- Local businesses need incentives. They also need to stick to commonly agreed rules.
- Private engagement is motivated by more than just profit. Specific local needs, networking, social responsibility, image and leadership aspirations are also powerful motivators.
- Local businesses are an integral part of all health systems and tend to be the most reliable providers in informal economies. They should not be overlooked by context analysis.
- The private sector tends to organically fill all the markets that have not been distorted by free money (including in the health sector).
The third module of the PSE in Health webinar series was the first of two parts that explore private- public partnership modalities to enable equitable access to innovative and affordable health technologies in low-income settings. Part I examined how collaboration between public-interest organisations and the pharmaceutical industries can strengthen research and development (R&D) of health products that address specific needs of low-income populations.
Summary
This session focused on the Product Development Partnership (PDP) model. PDP is a non- profit organisational structure that enables public, private, academic and philanthropic actors to develop drugs, vaccines, and other health products as public goods, usually targeting neglected diseases with little to no commercial incentives and that disproportionally affect people in low and middle income countries (LMICs).
Representatives from the Drugs for Neglected Diseases initiative (DNDi), Innovative Consortium Vector Control (IVVC) and Foundation for Innovative New Diagnostics (FIND) illustrated how entering in full partnerships with industry actors enabled them to develop new and innovative medical products.
Complementary expertise and resources is at the core of such partnerships. Each party covers the right segment of the value chain based on their strengths, thereby optimising the chances that the products under development will reach those in need. For example, Sanofi and Syngenta shared their compound libraries, R&D platforms and expertise for the development of, respectively, Fexinidazole®, a drug against the sleeping sickness, and Actellic®, a new generation of Indoor Residual Spray (IRS) insecticides for vector control in the fight against malaria. Meanwhile, DNDi’s network and infrastructure, which are close to the target patients, made clinical trials of Fexinidazole® possible and IVCC provided laboratories to test and develop Actellic® with resistant mosquito strains. The importance of complementary private-public partnerships was further emphasized by representatives of the pharmaceutical companies Merck and Novartis, who highlighted the different types of collaborations they engage in from discovery to clinical access. With a weak coverage of R&D ecosystem in LMICs, PDPs allows them innovate in areas they would otherwise not explore.
Most importantly, guest experts showcased the comprehensiveness of the role of PDPs. Beyond just bridging the R&D funding gap, partnerships with the private sector cover the entire market chain of new products. As such, they ensure that new drugs, vaccines and health tools appropriately address an existing need, target the right population, and that these products are effectively taken up through targeted market shaping interventions. For example, IVCC made sure to introduce alternative products in the IRS market to rotate with Actellic® and prevent the development of resistant mosquitos. FIND played a crucial role in the development of affordable COVID-19 rapid antigen diagnostics tests and their delivery at point-of-care within the ACT- Accelerator framework. Matching private actors across the value chain led to a significant reduction of diagnostics test costs and they ensured access to these products by building-up local manufacturing capacity in LMICs, coordinated negotiations and pooled procurement, and provided regulatory process support and policy guidance
Considering the whole scope, i.e. from R&D, delivery and all the way to access, is crucial to developing new effective health technologies. However, this requires a continuous, dynamic and transparent negotiation and planning process, embodied in a Target Product Profile (TPP). TPPs are technical documents that describe the target population, the interventions that are required and the minimal intervention characteristics. The best products include the «3As, 1Q formula» in their R&D and marketing framework
- Access: do we have the right R&D framework? Are we pushing towards the right target? Once we have a product, can it be delivered in a specific setting? Is the targeted health system able to set up a suitable supply chain for this product, such that it can be delivered to the right place at the right time?
- Acceptability: Is it the right formulation? Will it operate in a low-resource setting (e.g. outside of a cold chain)? Do the drugs have side-effects and can we remove them? Will the patients accept to use this product?
- Affordability: Is the price right?
- Quality of the product: lower prices should not compromise the product quality and effectiveness
In an effort to increase the efficiency of these efforts, the Special Programme for Research and Training in Tropical Disease, hosted by the WHO, has developed the Health Product Profile Directory, which provides guidance on priority needs in medical product R&D for neglected diseases and populations, as well as threats to global health. In identifying priorities, specifying minimum characteristics and translating them into technical language for R&D actors, TDR seeks to make an investment case for the development of products with low commercial incentives.
Key messages
- Given the long process of development and marketing of new health products, PDPs rely on long-term collaborations with selected partners.
- Partnerships are built around complementary of strengths, competencies and expertise.
- The incentives for private R&D actors to enter such partnerships are additional R&D funds and developing markets that would have otherwise remain untapped.
- The PDP model goes beyond just closing the R&D funding gap.
- PDPs take an end-to-end perspective of access to medical products, from discovery to delivery.
- Equitable access to medical products does not solely depend on affordable prices.
- PDP engagement requires careful planning at the very outset of R&D to ensure appropriate interventions that guarantee accessibility, acceptability, affordability and quality.
- Setting the right price of a new product is the result of a long, transparent and honest negotiation process that follows the product development pathway.
The fourth module of the PSE in Health webinar series was the second of two parts that focused on private-public partnership modalities that enable the equitable access to innovative and affordable health technologies in low-income settings. Part II explored different public-private partnership models that ensure quality of affordable medicines.
Summary
Poor quality medicines can have many adverse effects, not just for the patient’s health. Substandard medicines threaten public health with resurgent diseases or new resistances. They can also cause economic loss, and breach public trust. Counterfeit products are equally – if not more – problematic for both patients and the public, and are commonly found in low- and middle-income countries (LMICs).
Medicine quality can be compromised at various stages, from the production of active ingredients to patient uptake. Therefore, ensuring quality requires considering a multitude of aspects: formulation, effectiveness and stability of medical products, but also packing and labelling (is it understandable? Can the product be used correctly? Is it going to hold up under difficult environmental conditions?), shelf-life, or even appearance. Considering policy and financing is also critical, because new medicines and/or generic drugs are likely to cost more than existing or substandard ones on the market. Therefore, ensuring quality, as well as affordability and access, requires continuous interventions throughout the entire journey of a product, from laboratory to regulatory approvals and product readiness for the field.
Lower- and middle-income economies are particularly vulnerable to substandard and fake medical products. Specific instruments and programmes have been put in place to address their needs – WHO Prequalification of Medicines Programmes (PQP) of medical products, WHO Global Benchmarking Tool1 (GBT), regulatory systems strengthening programmes, Good Manufacturing Practices (GMP), and the push for the production of generic medicines, to name a few.
To learn more about the specific challenges, opportunities, and possibilities for donor organisations to contribute to quality assurance in LMICs, the SDC Health Network invited expert speakers, active in different areas of quality assurance in lower- and middle- economies and whose organisation engages in different private-public partnership modalities: Swiss TPH is a long-standing SDC implementing partner in various health-related projects; Medicine Patent Pool (MPP) sub-licences patents to generic manufacturers to produce high quality, yet low-cost, drugs for LMICs; QUAMED seeks to increase the base of reliable suppliers with quality assurance audits of pharmaceutical vendors and a certification programme that reflects medicine suppliers’ level of compliance to good storage and distribution practices; Swissmedic is the Swiss authority responsible for authorising therapeutic products, but also engages in strengthening regulatory systems in LMICs and building up capacity of national medicine authorisation agencies; and finally, Medicines for Malaria Venture (MMV), a Product Development Partnership (PDP)2 involved in the research, development and delivery of antimalarial drugs, is pushing towards bringing drug manufacturing closer to the patients.
In a round of brief presentations followed by a facilitated round table, guest speakers shared their experiences and views on how to balance access and affordability with quality of medical products.
Bottlenecks
The private sector services 60 to 70% of patients in LMICs, engaging private actors is therefore necessary. Yet, quality assurance systems are often unsatisfactory or even non-existent for the private sector in LMICs. With limited regulatory capacity in terms of financial resources, enforcement and sanctions, developing countries are particularly vulnerable to medical products of poor quality: 10% of drugs in circulation are substandard or counterfeit, with and alarming rise in the latter since the onset of the COVID-19 pandemic. Constrained purchasing power for both public procurement and self-financed patients, as well as the lack of knowledge and know-how of public and private actors alike on the importance of quality and which quality assurance measures can be taken, further undermine access to good medicines.
While manufacturing of medicines is concentrated in Asia (active product ingredients are mainly produced in China and finished generic pharmaceutical products in India), the African continent imports 80 to 90% of the finished products it consumes. This regional imbalance and the multiplicity of intermediary actors complicate regulatory control, as regulatory frameworks vary from one country to the other, traceability cannot always be guaranteed, and longer supply chains increase the odds of quality deterioration.
Disruptions in supply chains and protectionism measures during the COVID-19 pandemic have further highlighted the extent to which the production-consumption geographical divide can affect patients in LMICs. Ensuring the security of supply chains, while guaranteeing quality, has been challenging. Political accountability and visibility have pressured political leaders to focus on availability of medicines with a lesser regard for quality, or favoured local suppliers, not all of which are up to standards. With the experiences from the pandemic, the industry has observed a growing interest in diversifying the pharmaceutical production landscape and strengthening the global supply chain to ensure that medicines are closer to where the patients need them. However, building local manufacturing capacity can hardly happen from scratch. Resources being a limiting factor, capacity building focuses on actors with existing manufacturing capabilities, capacity and good market penetration prospects, i.e. with an existing market outreach network.
Finally, as show-cased by guest speakers, many quality assurance strengthening activities rely on voluntary-based mechanisms. If regulatory, control, and monitoring processes require too much efforts, private actors can simply decide not to opt in. For example, MPP’s model is based on sub-licencing to several generic manufacturers. The lack of exclusivity inevitably leads to price pressures. Yet, licencing agreements requires private manufacturers to take the necessary quality assurance measures to go through approval by a stringent regulatory authority, which discourages some actors. Willingness of actors is therefore key.
Opportunities
Guest speakers’ experiences have shown that private actors willing to invest in quality assurance training and measures are out there. They just need the right incentives. Guaranteeing that demand not only exists, but that it is also ready to purchase quality-assured products, is crucial. This has for example been the case for malaria and HIV drugs, where procurement is backed by big players, such as the Global Fund and other financing mechanisms. WHO prequalification has gone a long way in securing bulk purchasing.
However, new entrants in the generic medicine market face high costs in dealing with WHO pre- qualification and CMP standards, with little insurance on demand volume. This has notably been the case for non-communicable diseases like diabetes, for which out-of-pocket remains the main source of financing. PDP-like partnership models are active in alleviating some of these costs and risks for pharmaceutical companies. Quality certification programmes, such that of QUAMED, also contribute to securing demand by enlarging the pool of reliable and quality-assured pharmaceutical vendors and lowering transactional costs for procurers (governments, donor agencies, NGOs, etc.). In any case, it is critical to develop partnerships with an enabling environment for pharmaceutical actors to alert to problems as they arise and to co-develop solutions that emphasise quality considerations, as MPP’s experiences have shown.
Albeit, government support is essential to make demand forecasting easier and to foster good quality assurance practices through conducive policies and strong regulatory systems at country-level. Programmes like Swissmedic’s Marketing Authorisation for Global Health Products (MAGHP)3 seek to build up capacity of regulatory authorities. At the same time, they address the double standard in quality assurance between high- and lower-income countries by harmonising regulation processes between jurisdictions, since applicants to the programme must fulfil the same requirements as if they were to market a product in Switzerland.
Finally, bi-/multilateral donors and development and cooperation organisations can contribute to strengthening quality assurance by raising awareness amongst authorities and local stakeholders on the importance of quality to avoid the trade-off between availability and quality, especially in emergency situations. Collaboration with and capacity-building of all actors in the supply chain can help to effectively detect, report and respond to quality problems. Last but not least, quality assurance should be clearly and explicitly stated in all contracts and policies with partners in the field
Key messages
- The willingness of manufacturers and vendors to engage in quality assurance is key.
- This requires giving them the right incentives.
- Fostering quality requires a competitive space: if there is competition, there is an incentive to work on product quality, while lowering the price.
- In the case of voluntary-mechanisms, the price pressure from market competition can deter investments in quality assurance.
- Ensuring enough demand and responsiveness to quality-assured products once they enter the market are important components of competition.
- We cannot set aside the fact that the primary goal of pharmaceutical manufacturers and suppliers is to make profit. The goal is to make sure that the need to sell does not trump the need for quality.
- This requires strong regulatory systems, including monitoring and enforcement mechanisms.
- These require sufficient resources (financial, human), appropriate regulations, knowledge and know-how, but also the political will to put quality at the forefront.
- Actors in development and cooperation (NGOs, donors) can contribute by making pharmaceutical quality assurance explicit and clear in their policies and to all the stakeholders with whom they engage.
Organised in collaboration with the SDC Humanitarian Aid, the fifth module of the PSE in Health cooperation webinar series explored different modalities in which the private sector contributes to emergency preparedness and response
Summary
Most of the time, when we think of private sector engagement, we think about tapping into the business sector’s most obvious added-value: funding – maybe even more so in the humanitarian sector where operations are resource intensive. However, in this session, we learned that the private sector’s contribution goes beyond just cash.
In the most classic of modalities, private actors are contractors, supplying the materials or providing the services that allow for emergency and humanitarian interventions to take place. Humanitarian aid organisations rarely – if ever – have their own fleet of planes or helicopters to deliver medical supplies, or their own heavy machinery to, for example, drill and set up water pipelines. Hence humanitarian activities cannot bypass the private actors who provide these indispensable goods and services. However, even in the contracting model, the private sector’s expertise and competencies are, more often than not, complementary to that of emergency responders, such that they fill in the gap where humanitarian interventions would otherwise not be possible. This manifests in accessing areas with major safety issues, or by developing new products and technologies that address specific needs. During this session, we heard of various examples from the SDC Humanitarian Aid, such as chlorine solutions that are produced from salt using electrolysis directly on the field for targeted uses (e.g. vector control, hand disinfectant, surface disinfectant or to make water drinkable), thanks to a set of devices specifically developed for these contexts by a Swiss company. But, in other cases, local companies are contracted to develop on- site, one-off, tailored solutions, such as furnaces to safely burn medical waste.
In view of better understanding other ways in which private actors directly intervene in emergency settings, the webinar welcomed guest speakers working for organisations engaging in private-public partnerships in fragile context.
First, the Medical Expert Group is part of the Swiss Humanitarian Aid Unit (SHA), the emergency operation unit of the Federal Department of Foreign Affairs (FDFA) that intervenes in crisis situations. Experts are part of a wide pool of specialists selected and trained through the SHA, then deployed for short-term missions in areas affected by conflict or natural disaster. The Medical Expert Group’s work includes assessing the medical context, providing care for survivors, distributing health kits and supporting local hospitals. In the case of an epidemic, deployed experts work to limit the spread of the virus through preventive action with local authorities. The medical personnel sent to these areas comes from both public hospitals and private practices at the top of their field of expertise. The Geneva University Hospital (HUG) is one of SDC’s longest partner in this regard. HUG provides medical personnel for emergency interventions for a yearly flat-rate. In turn, the institution and its personnel benefit from unique training possibilities, where practitioners develop new skills to treat patients in difficult and low-resource contexts, which they would otherwise not encounter in Switzerland. However, these activities do not come without risks, neither for those deployed, nor for the institutions who employ them. Hospitals and other practices must reshuffle their personnel to fill in the gap of someone leaving for several days to weeks within a few hours’ notice. But most importantly, beyond just personal safety in the field, working in humanitarian contexts can have deep long-lasting, personal effects for those who are deployed and who might find it hard to readjust to their everyday personal and professional lives.
Secondly, the webinar learned from the African Risk Capacity (ARC), a specialised agency of the African Union that was established to help African governments strengthen their risk management system to better plan and be better prepared to extreme weather events or natural disasters. Based on its experience with droughts, ARC has been developing a new programme, the Outbreaks and Epidemics Programme (O&E), to help countries strengthen their health systems, to contribute to national capacity in risk profiling and response planning, and to provide rapid and predictable funds for countries to quickly respond to a public health emergency once it arises, thereby alleviating the human and economic impacts of disease outbreaks (Ebola, Marburg, Lassa fever and Meningitis). To do so, pathogen-specific risk profiles are drawn to better understand existing country-specific disease and epidemic risks, as well as existing gaps. Based on this assessment, a contingency plan is developed using costed response scenarios, after which, outbreak models with different impact simulations of possible interventions allow to assess whether a country is able to contain an outbreak. If not, the risk is transferred to private actors through an insurance plan. Negotiations with the private sector are on a continental risk basis, however contracts are signed at the country level, with specific insurance premium and threshold levels to activate payments. While insurance companies are risk-takers looking to diversify their portfolio, they will try to minimise their own risks and therefore incentivise governments to invest in system preparedness.
The final example showcased the activities of the Veolia Foundation, a not-for-profit organisation under the Veolia Group, which specialises in water, energy and waste solutions. On a voluntary basis, the foundation deploys experts from the private sector, including from its parent company, to assist in emergency contexts. In collaboration with national governments, NGOs (e.g. Médecins Sans Frontières) and international organisations, they provide needs-based solutions to ensure that affected populations have access to essential services, such as water, sanitation, energy production or waste management. The foundation also works with local companies to carry out some of its activities in the field, as they have better access to and knowledge of the area. These partnerships have led to win-win-win situations, where (1) local populations benefit from Veolia’s interventions and expertise, for example in long-term eradication of cholera in the Democratic Republic of Congo, (2) experts learn from working in the field and develop new products, and (3) local companies benefit from knowledge transfer, which elevates their standards to the international level and allows their business to grow and access funding from big donors.
With increasingly more complex settings that require humanitarian aid, contracts with the private sector are gaining in size and complexity as well. The SDC WASH Cluster, in collaboration with the International Committee of the Red Cross (ICRC), is now developing the International Humanitarian Infrastructure Platform (iHiP) to standardise contracts between humanitarian aid organisations and the private sector around the world to facilitate trust-building and accelerate operationalisation and deployment.
Key messages
- Humanitarian interventions are a market opportunity for the private sector to develop new services, new technologies, but also new forms of engagement with the public sector.
- The incentives for private sector to engage in the humanitarian sector can take multiple forms:
- Diversification of portfolio that guarantees company growth
- Reaching higher international standards, in the case of local private actors who might not have the means to invest in research and development; 2.3. Attracting new investors, both for local and international companies
- Creating new partnerships with other businesses
- Staying at the top of the expertise and knowledge of their field, most notably in the case of medical professional who receive specialised training and gain skills by working in conditions they would otherwise not encounter in their home country
- Promoting a positive image of the institution or the company.
- The risks involved in working in emergency settings represent nonetheless a disincentive for many private actors
- The private sector’s contribution tends to receive too little recognition, and yet their services are a necessity for emergency interventions.
- Acknowledging the private sector’s complementary competencies, skills and expertise is the first step in finding new opportunities, fostering more partnerships and strengthening collaborations between public and private actors that will, ultimately, better serve the populations in need.