Health Systems

The WHO and the Public-Private Partnerships Debate

This post was written by Elizabeth Montgomery Collins, MD, MPH, DTM, Global Health Council individual member and delegate to the 142nd WHO Executive Board meeting. In January, Global Health Council (GHC) hosted a delegation to the 142nd Session of the World Health Organization (WHO)’s Executive Board (EB) Session. View complete WHO EB updates.

142nd WHO EB Meeting in session. Photo credit: Danielle Heiberg, Global Health Council

A recurring theme at the World Health Organization (WHO) 142nd Executive Board meeting (EB142) in Geneva was the extent to which the WHO should engage in public-private collaborations to achieve policy objectives such as universal access to medicines and vaccines.  Most agenda items prompted two to three minutes of commentary from most of the 34 countries currently serving on the Executive Board, as well as additional comments from countries with observer status that could speak but not vote.  This summary is intended to provide an overview of those comments and a sense of the WHO debate over public-private partnerships.

Agenda Item 3.3 Public health preparedness and response (and affiliated items EB142/8, EB142/9, and EB142/10)

Representing the United States, Garrett Grigsby, Director of the Office of Global Affairs at the U.S. Department of Health and Human Services, articulated the U.S. position that the WHO would be better served by investing in prevention now rather than responding to emergencies later.  He moreover argued that achieving universal access to healthcare in many countries will require the kind of resources only available through private sector investment and that the WHO should, therefore, utilize private sector partnerships to drive healthcare access availability down to the individual level.

Conversely, the People’s Health Movement, a global network of health activists, expressed concern with “the rise of private-public partnerships for global health security such as GAVI and CEPI,” concluding that such collaborations can “potentially undermine WHO’s leadership and confer undue influence to the private sector.”

Agenda Item 3.6 Addressing the global shortage of and access to medicines and vaccines

Director Grigsby reported that in 2017 the U.S. Food and Drug Administration (FDA) set an all-time record for approvals (763) granted for generic medications.  This increase in approvals reflects the growing understanding that generic medications will play an essential role in expanding global access to medicines and vaccines.  Director Grigsby further suggested that the private sector companies who develop and manufacture such medicines would make a logical (and perhaps indispensable) partner in the WHO’s efforts to overcome access barriers (such as scarcity and price) to medicines and vaccines.  The U.S. also emphasized the importance of innovation, which typically originates in the private and academic sectors.

The representative from Portugal, however, cautioned that private sector partnerships fail to advance the three keys to global access:  transparency, fair pricing, and joint public procurement.  The representative specifically pointed out that a “lack of transparency regarding costs of production, research and development, and prices paid by other Member States and procurement agencies results in a lack of power to negotiate and a reliance on mechanisms for comparison such as international reference pricing, which is likewise opaque.” In addition, the “lack of transparency stimulates corruption, bad governance and allows for abuses such as the very high prices that are currently being imposed for some innovative medicines, namely for cancer, Hepatitis C or some new gene therapies.”

A number of non-state actors also offered comments on Agenda Item 3.6.  Dr. Mychelle Farmer of the Global Health Council delegation, in a statement supported by the American Academy of Pediatrics (AAP), which represents 66,000 pediatricians, and NCD Child, a global coalition for prevention and treatment of non-communicable diseases (NCDs), stated that the WHO should consider pursuing Product Development Partnerships to target specific diseases, including non-communicable diseases.

Agenda Item 3.8 Preparation for the third High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases

Regarding the prevention and control of NCDs, the U.S. delegation highlighted the critical need for “collaboration and partnerships across sectors.”

Likewise, Canada, speaking on behalf of Canada, the Caribbean, Central and South America, and Mexico, said, “To effectively address the growing epidemic of NCDs and manage their shared risk factors we believe a whole-of-government and a whole-of-society approach should be promoted. Strong political will, investments and cooperation are necessary to tackle the social, economic, political and capacity challenges underpinning NCDs and to encourage action across sectors as well as multi-stakeholder engagement and partnership.”

The Global Health Council, supported by NCD Child, the AAP, and the International Federation of Psoriasis Associations, echoed this sentiment and indicated that the WHO must create linkages between non-state actors and non-health sectors to effect lasting change.

Commentary on Twitter, however, suggests that the European Union statement, while welcoming global efforts to combat NCDs, opposes corporate involvement in the effort, referencing the UN model policy on preventing tobacco industry interference.

Agenda Item number 3.9 Preparation for a high-level meeting of the General Assembly on ending tuberculosis (TB)

The U.S., which claimed to be the largest funder of TB prevention, treatment, and research worldwide, stated that the U.S. is committed to domestic TB elimination and believes that with effective collaboration, and increased multi-sector engagement, the WHO can end TB worldwide.

Agenda Item 4.2 Physical activity for health

The NCD Alliance noted that the inadequacy of existing resources to achieve the WHO’s physical activity targets may require “cross-sectoral collaboration, co-investments and accountability” but that any such collaborations should be “informed by WHO recommendations on restrictions of marketing of unhealthy foods and non-alcoholic beverages, and the Commission on Ending Childhood Obesity” and other “potentially incompatible partnerships e.g. those with the alcohol, gambling and fossil fuels industries, whose products and services drive modifiable NCD risk factors and contradict sustainable development principles.”

Ilona Kickbusch, Director of the Global Health Centre of The Graduate Institute of International and Development Studies in Geneva, similarly tweeted that “the food and drinks industry are complicit to the NCDs epidemic and must change”.

Meanwhile, the Infectious Diseases Society of America (IDSA) suggested that the WHO must strengthen its own research and vaccine development, and that it would be counterproductive to exclude private sector contributions when addressing the health of all people everywhere.

Conclusion

Although the debate continues, the WHO has acknowledged the potential benefits of public-private collaborations.  In a January 19, 2018 article in The Wire entitled “WHO Gets to Work: 2018 a Litmus Test for New Team”, for example, the WHO reportedly has indicated a willingness to engage with a range of non-state actors, including private entities, because “outreach to such actors is critical for WHO’s work.”  The WHO likewise acknowledges in its revised Global Plan for Work GPW13 that “Non-State actors and, in particular, the private sector can also contribute to [universal healthcare] UHC in service delivery, innovation, investment, and as employers.”  At the same time, the WHO continues to reaffirm that it will always “speak up against practices from any sector, including industry, that, based on evidence, are harmful to health.”

  • View Global Health Council’s 2017 World Health Assembly statement for Agenda Item 23.3: Engagement with non-state actors.
To Move Forward Is To Move Together: Creating Collective Action Through Roundtables

This post was written by Melissa Chacko, Policy Associate, Global Health Council.

The global health advocacy community is diverse and functions as a conglomerate of roundtables, working groups, and coalitions (hereafter referred to as Roundtables). Roundtables can work independently or collectively, bringing advocates and researchers across various sectors together to discuss global health policy issues and to increase U.S. funding for global health accounts. The Roundtables’ impact on global health policy is a culmination of these groups’ work such as sign on letters, meetings on Capitol Hill, advocacy around legislation, and engagement with the administration. For organizations that advocate for U.S. investment in global health, the Roundtables amplify this work, as they provide strategy, build a collective voice, and push for a comprehensive holistic approach to global health delivery and care.

Provides Strategy

Roundtables give organizations the opportunity to share their knowledge with each other. Sharing this knowledge allows organizations to be current and devise collective action.

Aaron Emmel, Manager of Global Health Advocacy Initiatives at the American Academy of Pediatrics (AAP), explained, “Information sharing is essential for roundtables to move forward with advocacy strategies.” Aaron is a member of the Steering Committees for the Noncommunicable Diseases Roundtable and the Maternal, Newborn, and Child Health (MNCH) Roundtable, and the working group for A Global Agenda for Children (early childhood development). AAP also participates in other advocacy groups such as the International Family Planning Coalition; the civil society group organized by Gavi, The Vaccine Alliance; the Water, Sanitation and Health (WASH) Working Group; and the 1000 Days (nutrition) Working Group.

Aaron elaborated on how sharing knowledge brings different viewpoints to the table. “AAP shares information on pediatric health, from child survival to NCDs and chronic care. Other partners such as maternal health experts including the American College of Gynecologists, share complementary information that helps to tell a fuller story. Together we are able to add to each other’s credibility.”

Lisa Schechtman, Director of Policy and Advocacy, at WaterAid, who sits on the Steering Committee for the MNCH Roundtable and is also the co-chair for WASH Working Group, said, “Sharing information allows roundtables and individual organizations to be strategic and current in advocacy issues that organizations work on.” Lisa continued, “For smaller teams like WaterAid, and [as] one of the few organizations that work in the WASH space, having these spaces allow us to amplify our contribution as few WASH advocates are able to do that.”

Builds a Collective Voice

Roundtables build a collective voice around global health issues, bringing multiple focuses together to create stronger messages to send to Congress and the administration. Aaron emphasized this point, “Diverse voices show consensus around global health issues and allow us to validate programmatic evidence from different perspectives. There is not necessarily a national constituency for global health so it is important that roundtables allow for coordination, for members to come together and present evidence to policy makers and agencies to reinforce global health agendas.”

Lisa reinforced the power of collective voice and that “we are stronger together.” WASH is one example of this. Lisa added, “WASH focuses on the outcomes of providing services and most of these outcomes are linked directly to the goals of the MNCH Roundtable. The MNCH Roundtable helps to provide context to do what we do and MNCH-focused groups can learn from WASH and consider our inputs and strategies. This gives us credibility for the health benefits of WASH and our position in the global health community doing advocacy on WASH.”

Comprehensive Holistic Approach

Roundtables provide a space for points of integration and create holistic approaches to global health agendas. Aaron explained, “For the Reach Every Mother and Child Act (Reach Act), the child survival groups needed buy-in from the maternal health groups to create a strong message to legislators. Bringing diverse voices to policy makers shows that we are united around this issue. For NCDs, we serve as a bridge for maternal and child health; without the NCD voice, global maternal and child health policies and interventions would not necessarily include chronic illness, and without the maternal and child health voice NCD policies have not adequately addressed the unique needs of children and youth.”

On WASH integration, Lisa said, “Integration was the original reason we joined the MNCH Roundtable several years ago. Although members of the Roundtable do WASH service delivery there was almost no health organization working on WASH advocacy. WASH underlies the success of the MNCH and Nutrition community which builds more WASH champions and raises opportunities and issues.” By being a part of the MNCH Roundtable, Lisa said that “WASH is now at the table for the MNCH annual appropriations process.”

Moving Forward

To move global health forward, is to move together. Roundtables allow the global health advocacy community to come together, find areas of integration and collaboration, and build a collective voice. Lisa discussed this benefit and used WASH integration as an example. “Being a member of the Roundtables and of Global Health Council has worked hand in hand.” Lisa emphasized, “Both memberships increase the profile of WASH as a health issue and create new partnerships, in addition to the opportunity to work with Global Health Council staff.”

Looking forward, the global health advocacy community’s collective voice is now more important than ever. Aaron added, “We work in different spaces but we recognize that there is a shared agenda and vision to help and maintain the role of America as a trusted leader and partner for global health issues.”

Global Health Council works with the Roundtables to support information sharing, coordinate advocacy efforts, and be a part of the collective voice of the global health community. If you are interested in attending roundtable meetings or would like to find out more information please email advocacy@globalhealth.org.

Toolkit: Advancing Women Leaders in Africa

ACCESS THE POLICY TOOLKIT

In March 2017, Her Excellency Dr. Joyce Banda, former President of Malawi and Founder of the Joyce Banda Foundation, launched her paper, “From Day One: An Agenda for Advancing Women Leaders in Africa” as the crux of her research while serving as a Distinguished Fellow at the Woodrow Wilson Center. To achieve this end, Dr. Banda published “From Day One: An Agenda for Advancing Women in Africa” which details the history of women’s leadership in Africa and some of the challenges and opportunities women face on their leadership journey. The paper includes five key recommendations for promoting women’s leadership in Africa:

1) Enhance political will to empower girls, and appoint qualified women to leadership positions

2) Mobilize rural leadership, families, and communities to promote the change of mindsets and behavior around women and girls

3) Strengthen networks between current and emerging leaders

4) Allocate resources towards data collection and analysis, and research around women and leadership

5) Create the legal environment to advance women in positions of leadership

In the second phase of her research, Dr. Banda spearheaded the creation of a toolkit to provide actionable steps to implement the recommendations.

ASTMH Kicks Off 2017 Annual Meeting by Premiering Its First Society-Level Medal Named After A Female Icon In Tropical Medicine

This blog post was written by Doug Dusik, Senior Communications Executive, American Society of Tropical Medicine and Hygiene (ASTMH)The American Society of Tropical Medicine and Hygiene, founded in 1903, is the largest international scientific organization of experts dedicated to reducing the worldwide burden of tropical infectious diseases and improving global health. The organization accomplishes this through generating and sharing scientific evidence, informing health policies and practices, fostering career development, recognizing excellence, and advocating for investment in tropical medicine/global health research. ASTMH is a 2017 Global Health Council member.

The American Society of Tropical Medicine and Hygiene (ASTMH) kicked off its 66th Annual Meeting in Baltimore on Sunday by presenting a new honor and first for the Society: the Clara Southmayd Ludlow Medal, the first named after a female icon in tropical medicine. The ASTMH Council recognized the absence of a Society-level medal named after a woman as an oversight and announced its plans at the 2016 Annual Meeting, soliciting nominations earlier this year. The new medal recognizes honorees of either gender for their inspirational and pioneering spirit, whose work represents success despite obstacles and advances in tropical medicine. The medal was named for Clara Ludlow (1852-1924), the Society’s first female member and its first non-MD member, an entomologist with scientific zeal and tenacity who battled the odds of age, gender and skepticism of women in the sciences to advance the understanding of tropical medicine.

• Front of ASTMH’s new Clara Southmayd Ludlow Medal, its first named after a female tropical medicine icon.

The medal’s first recipient selected is Ruth S. Nussenzweig, MD, PhD, of New York University of Medicine, whose extraordinary contributions forever changed malaria vaccine research at time when it was thought that a malaria vaccine was impossible. Her work, with husband and collaborator Victor Nussenzweig, showed otherwise, paving the way for today’s malaria vaccine efforts. Dr. Nussenzweig was unable to attend the awards ceremony but her son, Andre, accepted the medal on his mother’s behalf. Also in attendance were Dr. Nussenzweig’s grandsons, Julian and Samuel.

• Back of the Ludlow Medal bearing the name of its first recipient, Ruth S. Nussenzweig.

The Society was equally delighted to have two family members of Clara Ludlow: Elizabeth Thomas and Sarah Brown Blake. Elizabeth Thomas is a second-year doctoral student in the Social and Behavioral Interventions Program, Department of International Health, Johns Hopkins University Bloomberg School of Public Health in Baltimore, and Sarah Blake Brown is a Postdoctoral Scholar at the Betty Irene Moore School of Nursing at the University of California, Davis. Her professional nursing experience is rooted in community and public health with a focus on Maternal Child & Adolescent Health. Clearly, the spirit of Clara Ludlow is in their DNA.

Elizabeth and Sarah bestowed the Ludlow Medal on Andre Nussenzweig. ASTMH President and awards ceremony moderator Patricia F. Walker, MD, DTM&H, FASTMH, described it as a way of history connecting to the past.

The ASTMH Annual Meeting continues through Thursday, when National Institute of Allergy and Infectious Diseases Director Anthony S. Fauci, MD, will deliver a special plenary session. Other highlights included a keynote address by Paul Farmer, MD, PhD, Co-founder and Chief Strategist of Partners In Health (PIH) and a chance for attendees to give back to the global health community by receiving their annual flu shot via Walgreens’ Get a Shot. Give a Shot.® campaign through the United Nations Foundation’s Shot@Life campaign.

 

The Complex Truth of Health Tech: Why Greater Ultrasound Availability Doesn’t Always Benefit Patients

This post originally appeared on the NextBillion website. This guest post was written by Catharine Taylor, Vice President of Health Programs at Management Sciences for Health (MSH), along with fellow colleagues Dai Hozumi, Senior Director for Health Technologies and Joann Paradis, Strategic Communications Advisor. MSH is a nonprofit global health organization and Global Health Council member organization. 

A pregnant woman is given an ultrasound. (Photo Credit: Rui Pires)

Advances in health technologies have reshaped the lives of communities, families and individuals, undoubtedly contributing to better health outcomes around the world. For the most vulnerable populations, technology may significantly improve access to preventive, diagnostic, and treatment services and help increase demand for greater quality care. Yet, despite their potential, new technologies can also add new challenges, risking potential gains in quality, safety or cost. Particularly in settings where health systems are weak, the introduction of technological interventions requires thoughtful execution.

Take the case of ultrasound technology. Used during routine antenatal visits, ultrasound scans have the potential to change the scenario for many pregnant women who face complications. If combined with proper skills, knowledge and quality-assurance, this technology could help identify high-risk pregnancies and establish an accurate gestational age in order to improve obstetric care. Many low- and middle-income countries are seeing a rapid introduction of this technology into their health systems, accelerated by a dramatic rise in demand that has been driven in part by medical staff, local advertising, falling prices, and a greater availability and range of ultrasound devices.

Yet ultrasounds are not proven to lead to better outcomes for women and newborns in low-income countries, and without the proper focus on their introduction and use, we risk the efficiency and effectiveness of health systems and expose women and newborns to unnecessary technological interventions. That’s why, just last year, the World Health Organization (WHO) issued recommendations on antenatal care endorsing one scan in early pregnancy in low-income countries alongside guidance for staff training and proper use of this technology.

THE REALITIES ON THE GROUND

We recently visited a health center in the outskirts of Kampala, Uganda’s capital city, which had just introduced an ultrasound machine for antenatal care. Like many others, the doctor at this health center was looking to take advantage of this imaging technology to provide better care to his patients. Despite the guidelines calling for only one ultrasound scan in early pregnancy, a woman we met proudly shared with us four photographs she obtained through repeated scans, even though there were no abnormalities or issues identified throughout her pregnancy. We’ve encountered instances like these in several countries, bringing into question essential governance aspects including the right policies, oversight, and mechanisms for evidence-based decision-making, and highlighting potential ethical issues around the use of this technology. Was the doctor equipped with the right skills or understanding behind the proper use of ultrasound? Were there additional unnecessary costs and burdens for the woman and her family, who may have been lulled into a false sense of security that repeated scans would ensure a better outcome for mother and baby?

Given the WHO recommendation and the ubiquity of ultrasound devices, the real question becomes: How do we ensure health systems are robust enough to effectively and safely take advantage of this technology?

There appear to be major gaps in policies, planning and oversight to support the introduction of ultrasound technology, especially outside the more specialized hospital setting. At Management Sciences for Health, we support governments in their efforts to build strong adaptive systems that meet the needs of the populations they serve. The case of antenatal ultrasound highlights three specific issues:

Adequate procurement and a strong supply chain: Our experiences in helping governments improve procurement and supply chain management highlight critical issues that affect how technology takes root and delivers on its potential. Ultrasound technology has advanced to allow for different types of imaging and functionalities, ranging in price from USD $2,000 to $15,000. Determining which one meets the specific needs of a local health system requires thoughtful procurement policies and effective distribution and placement. In addition to regular supplies such as jelly, paper towels, printers, etc., the processes and costs required to maintain the accuracy and sensitivity of the ultrasound equipment, including servicing malfunctioning machines, must be carefully considered within health systems – and these are influenced by the machine specifications. Of course, power supply requirements are also important considerations for health centers that frequently experience electricity outages and voltage fluctuations.

A well-functioning referral mechanism: Because the effectiveness of this intervention relies on the ability of screened women to seek care depending on the screening results, it is also essential for a functional referral system to be in place. Health workers and sonographers must be able to support informed decision-making, and women with high-risk pregnancies must be able to reach the referral hospital – one which must be equipped to handle the level of care that screening indicates, including emergency obstetric and newborn care. The value of the ultrasound screening is diminished when this is not in place, or when women are unable to cover the additional costs of transportation and hospital care and treatment. As illustrated in a study published recently on the implementation of ultrasound technologies in the Democratic Republic of Congo, these challenges represent enormous barriers for the most vulnerable populations.

Strong governance for health: As a screening tool, the ultrasound depends on a process or a decision-making algorithm that allows health workers to adequately act on the information gathered. Nurses and midwives – the cadres who might typically perform this intervention at health centers – must have the policies, consistent training and ongoing supervision to use the technology, analyze the results and take appropriate actions. These elements, and a sound system of quality assurance and data management, will protect the health of women and newborns and prevent health workers from misdiagnosing patients.

Above all, to realize the power of technology in any setting, but most importantly in low-resource countries, we must understand their specific circumstances, and support governments to establish appropriate policies, good governance, and ethical standards as a foundation for appropriate use of technology. This requires structural changes within the health system, and partnership with businesses involved in the manufacturing and selling of ultrasound devices. Only then can we ensure that ultrasound technology – or any technology – delivers on its promise.