Geneva Health Forum Archive

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Public-Private Partnerships: Beneficial or Undermining?

Author(s): Louis J. Currat1
Affiliation(s): 1Former Executive Secretary, Global Forum for Health Research, Geneva, Switzerland
Key issues: Many infectious diseases affecting the developing world are potentially treatable in the longer term. However, economic disincentives have resulted in underinvestment in medical research for new vaccines and medicines targeted at these diseases. Thus, of the more than 1200 drugs that reached the global market in the past three decades, only an estimated two to three per cent were for tropical infectious diseases that primarily affect the poor. Worse yet, three million children die each year from diseases that could have been prevented with existing vaccines (for example vaccines against hepatitis B and Haemophilus influenzae type b), underlining the huge economic, social and cultural obstacles existing between the availability of products and their accessibility by poor populations. The main reasons for this situation are that, on the one hand, high costs and inadequate commercial returns have resulted in the withdrawal of the private commercial sector from investments in tropical disease research and commercialization of health products for the poor populations of developing countries. On the other hand, the public sector has concentrated its financing on basic health research and generally lacks the expertise, mechanisms and resources to discover, develop, register and commercialize new products. In other words, there is a disconnection (or several) in the pipeline for producing, developing, and delivering health products to the poor between the public and private commercial sectors and these disconnections may be different for different diseases.
Meeting challenges: How to reconnect and/or reinforce this pipeline? The solution has to come from joint undertakings of the public and private sectors. In many cases, the initiative to launch a public/private partnership is likely to come from the public sector, as the sector is ultimately responsible for ensuring that the poor have access to health products. It may also come from civil society organizations, pursuing a global health objective with private resources. Examples also exist where the initiative was taken by the private commercial sector.
Conclusion (max 400 words): When are PPPs needed? In short, one could say that the larger the disconnection in the product discovery/delivery pipeline between the public sector and the private commercial sector, the higher the rationale for launching a PPP. Are PPPs the only strategy to reconnect and reinforce the discovery/delivery pipeline? No, the public sector may decide to use push and pull interventions to help correct the structural problem of under-investment in the diseases of developing countries. If the disconnection is particularly large, it may choose to use push and pull interventions together with support to specific PPPs in order to speed up the impact on the health of poor populations. Do PPPs always work and are they always cost effective? With good management, the benefit/cost ratio of PPPs may be very high, i.e. the benefits of joint action may be much larger than what each institution could obtain separately for the same amount of time and resources invested. In cases where the overall estimated benefits become limited, while the costs remain high, it is justified to stop the investment in the partnership. To illustrate these points, the presentation will draw upon a few examples of actual PPPs.

Public Responsibility in Research and Development Partnerships

Author(s): Bernard Pécoul1
Affiliation(s): 1Executive Director, Drugs for Neglected Diseases Initiative, Geneva, Switzerland
Key issues: A fatal imbalance exists in the investment in new drugs for neglected diseases, such as sleeping sickness and leishmaniasis, versus diseases prevalent in wealthy countries. From 1975 to 2004, of the 1,556 new drugs marketed only 21 just over one percent were for infectious tropical diseases and tuberculosis, in spite of the huge need. So, not only are the poor in developing countries disproportionately suffering from curable diseases, but their needs are woefully unmet by the existing model of drug development.
Meeting challenges: This disparity is now widely acknowledged and is being addressed by new research as well as new initiatives. Several research initiatives have been set up in the last 5 years to address this issue, e.g., the Drugs for Neglected Diseases Initiative (DNDi), Medicines for Malaria Venture, and TB Alliance. The challenge here lies in procuring full financial and political support from governments so that the initiatives can achieve their goals of developing and delivering desperately needed, new, effective, needs-oriented medicines to neglected patients. Currently, only 16% of funding for these initiatives comes from governments, while almost 80% comes from philanthropic organisations. This is unsustainable. The importance of public responsibility in providing equitable access to these health tools is an essential part of DNDi’s message as a not-for-profit research organisation that works in close collaboration with public and private partners in both developing and developed countries. The need for increased public support of essential innovation for neglected diseases is a growing global concern. Governments are being urged to lose no more time in supporting new funding mechanisms for neglected disease research and development and to create a favourable environment to stimulate R&D. A handful of Innovative Developing Countries such as India, South Africa, Brazil, etc. are becoming more proactive in the field of drug R&D. Yet innovation in drug discovery for neglected diseases remains a critical gap.
Conclusion (max 400 words): This message has recently gained ground at the WHA 2006, which voted to adopt a resolution to establish a global strategy and a plan of action directed at public health, innovation and essential health research. These are positive steps towards addressing the greater problem of R&D for neglected diseases. Much more remains to be done.

Impact of Global Health Initiatives (GHIS) on the Health Workforce in Burundi, A Post-Conflict State

Author(s): J. Cailhol*1, T. Mathole1, A. Parsons1, D. Kandondo2, I. Ndayiragije2, T. Niyongabo2, D. Sanders1
Affiliation(s): 1School of Public Health, University of Western Cape, Bellville, South Africa, 2National Center for HIV Reference, Bujumbura, Burundi
Keywords: Burundi, health workforce, global health initiatives, health system strengthening, public sector, health financing
Background:

Burundi’s health system was weakened by a long-lasting civil war and has subsequently faced severe economic constraints and massive brain drain. In 2008, the number of health workers in Burundi’s public sector was insufficient by international norms. An average of 0.2 physicians served every 10,000 inhabitants, with 1.4 nurses for every 3,000 inhabitants, and 68 pharmacists throughout the entire country. Eighty percent of the general practitioners and 50% of the nurses work in urban areas although 91% of the population lives in rural areas. Annual salaries in the public sector range from US$ 62 to a maximum of US$ 152 for a specialist. Humanitarian aid, mainly prevailing during the war, was progressively replaced by GHIs activities from 2002 (GAVI, the Global Fund and the World Bank Multisectoral AIDS Program). By 2006, 76% of total health expenditure was externally financed. The GFATM contributes the largest amount, at 37% of the budget. Estimated adult HIV prevalence was 2% in 2007.VThe study aimed to understand the impact of GHIs on the health system in Burundi, in this post-conflict context, with a special focus on human resources for health (HRH).

Methods:

Qualitative and quantitative data were collected in Burundi between January and May 2009, from 14 facilities in 3 provinces (one urban and 2 rural) and from national and provincial levels. Qualitative data consisted of semi-structured interviews with key stakeholders and key informants whereas quantitative data consisted of records or reports review and analysis of questionnaires conducted with HRH and patients at facility-level.

Results/Conclusions:

GHIs have contributed to capacity building in HRH, but in a selective way. GHIs have contributed to multidisciplinary HR trainings, but in sectors specific to GHIs’ focal diseases, though some have expanded to health system strengthening, such as GAVI, through a specific program, or to more integration between TB and HIV. Organizational structure, such as the creation of a specific Ministry dedicated to HIV or, to some extent, the operating system of the National AIDS Council, have undermined the integration of GHIs and Governments programs, creating parallel supervision, monitoring and evaluation and supply systems, thus increasing the workload. Conditions of use of GHIs funds were different between Non Governmental Organizations (NGOs) and public sector, especially with regards to salary top-ups. As a result, general working conditions within the public sector have seen little recent improvement. This has led to create inequitable groups of patients and HRH, depending on their affiliation to NGOs or public sector, with regards to the package of care or working conditions. The service delivery was also affected within the public sector: in rural areas, HIV prevalence continues to increase, whereas it has been stabilized in urban areas. Special attention should be given to HRH as the core of the health system. Improving the efficiency of GHIs funding requires health workforce strengthening, through revising HRH policies, training curricula and salaries. On one hand, pooling donors’ funds for such initiatives could be highly efficient, as proposed recently in high-level fora, but the performance and the quality of HRH should be comprehensively and independently assessed in parallel. The issue of sustainability of such initiatives should also be addressed. On the other hand, government should also be held accountable for caring of his own health workforce. It has to be noted that Burundese government is far behind the target of 15% of national expenditure for health sector and has been recently challenged by a months-lasting national strike for living wages by public sector nurses and doctors.

Health and Foreign Policy: Influences of Migration and Population Mobility

Author(s): O. F. Olugbemi1
Affiliation(s): 1Chief Executive Officer, World Hope Foundation, Festac Town, Nigeria
Keywords: International, globalization, migration, population, mobility
Background:

International interest in the relationship between globalization and health is growing, and this relationship is increasingly figuring in foreign policy discussions. Although many globalizing processes are known to affect health, migration stands out as an integral part of globalization, and links between migration and health are well documented. Numerous historical interconnections exist between population mobility and global public health, but since the 1990s new attention to emerging and re-emerging infectious diseases has promoted discussion of this topic. The containment of global disease threats is a major concern, and significant international efforts have received funding to fight infectious diseases such as malaria, tuberculosis and HIV/AIDS (human immunodeficiency virus/acquired immune deficiency syndrome). Migration and population mobility play a role in each of these public health challenges. The growing interest in population mobility’s health-related influences is giving rise to new foreign policy initiatives to address the international determinants of health within the context of migration. As a result, meeting health challenges through international cooperation and collaboration has now become an important foreign policy component in many countries. However, although some national and regional projects address health and migration, an integrated and globally focused approach is lacking. As migration and population mobility are increasingly important determinants of health, these issues will require greater policy attention at the multilateral level.

Results/Conclusions: Modern migration is fuelled by preexisting social, political and economic considerations, as well as by discrete environmental and political events, including disasters and humanitarian crises.

Global Public-Private Partnerships and Global Health Governance

Author(s): Eduardo Missoni1
Affiliation(s): 1Faculty of Sociology, Università degli Studi di Milano Bicocca, Milano, Italy
Key issues: Partnership, a good feelings evocative concept, is one of the trendiest key words in the international development jet set today. Repeatedly, declarations and commitments summarising international events conclude launching new global partnerships to solve the problems they have been addressing. The need for a wide commitment and shared responsibilities in the pursuit of development goals is often being mystified with the establishment of structured narrowly focused public-private partnerships whose promotion often responds more to ideological criteria than to sound comprehensive evaluation of costs and benefits. The notion of partnership for development is not new, however in the language of international meetings sponsored by, or with the participation of, UN agencies and other international and bilateral public actors, the rhetoric of partnership has now become dominant assuming the need for public-private joint-ventures, notwithstanding the lack of any evidence for that declared need.
Meeting challenges: Indicated as the eighth Millennium Development Goal and otherwise understood mainly in terms of shared values, goals, commitment and responsibilities, in the text of the Millennium Declaration the idea of partnership is translated into a pledge for strong partnerships with the private sector and civil society organizations in pursuit of development and poverty eradication. At the eave of the 21st century, Global Public-Private Partnerships have become one of the most notable features of the global arena. Pretending lack of public resources where the reality is one of reduced public commitment and of progressive privatization of international aid the GPPP model is repeatedly proposed at every Summit as the answer to the most varied and dramatic issues that the world is facing today. Including the GAVI which served as a prototype and the GFATM mostly imposed by a preconceived political agenda, at present there are more than 90 different health-related GPPP, duplicating efforts and further fragmenting global action for health, with heavy consequences also in terms of governance of national health systems and provision of health-care of beneficiary countries.
Conclusion (max 400 words): GPPPs offer easy quick-fix solutions to avoid more complex and disturbing global political rethinking and decisions. They involve issues of growing concern that need to be understood in the wider socioeconomical context of dominating neo-liberal ideologies that have influenced public policy since the early 1980s, with a growing commercialization of health care and the incapacity of WHO to keep up to its mandate and leadership. Important strategic decisions about health policies, appear to be taken in the new public-private setting, while WHO’s own legitimate authority is undermined, and its role reduced to pure technical assistance, in times when global health governance is widely felt as a critical issue.

Do Global Funds Really Facilitate Access to Health?

Presenter(s): Lola Dare, Marcos Cueto, Wibulpolprasert Suwit
Chair(s): Elisabeth Fee, Bernardino Fantini
Author(s): Elisabeth Fee1, Bernardino Fantini2, Marcos Cueto3 Lola Dare4, Wibulpolprasert Suwit5
Affiliation(s): 1Chief, History of Medication Division, National Library of Medicine, USA, 2Director, History of Medicine and Health Institute, Faculty of Medicine, University of Geneva, Switzerland, 3Professor Principal, Universidad Peruana Cayetano Heredia, Peru, 4Executive Secretary, African Council for Sustainable Health Development, Nigeria, 5Ministry of Public Health Advisor, Ministry of Health, Thailand
Summary (max 100 words): Numerous international funds have been set up in recent times to address global health challenges such as HIV, TB and malaria, in an effort to provide sustainable funding for selected diseases affecting billions of people in the poorer regions of the world. Despite impressive investments in terms of money and stakeholders  involvement at national and international levels, enabling the scaling up of specific health initiatives, the collective impact of these initiatives has sometimes created or exacerbated problems such as the poor coordination or duplication of programmes, heavy burdens on local health practitioners, variable degrees of country ownership, and a lack of alignment with country systems. Relying on the establishment of inclusive partnerships, financial institutions like the Global Fund to Fight AIDS, Tuberculosis, and Malaria do not take full responsibility for implementing funded programmes which require the active participation of partners in proposal development and realization (through Country Coordinating Mechanisms). One of the major reasons for the apparent ineffectiveness of global interventions is the historical weakness of the health systems of underdeveloped countries, which contribute to bottlenecks in the distribution and utilisation of funds. What are the pros and cons of the global funds from different country perspectives? In theory, the global funds programmes are to be continued and sustained in the long term by the countries themselves. Is this a reasonable expectation? Is the money coming into the global funds programmes (from the donors and also the recipient countries) new money, or is it simply being shifted from one health programme to another? How can the funds best support equity, universal coverage, and sustained improvement in health systems? performance? What are the key steps needed to implement the Paris declaration, with its guiding principles of ownership, harmonisation, alignment, results, and mutual accountability? This round table session will debate the pros and cons of the ways the global funds work (or fail to work) in practice and try to answer the above questions.

Partnerships to Promote Global Public Health Security

Author(s): David L. Heymann1
Affiliation(s): 1Representative of the Director-General for Polio Eradication, World Health Organization, Geneva 27, Switzerland
Key issues:

The emergence of new infectious diseases such as Severe Acute Respiratory Syndrome (SARS) and avian influenza A (H5N1); and the re-emergence of others such as cholera and yellow fever combined with the increased speed and volume of international travel and trade have alerted countries to the ease with which infectious diseases can cross national borders and defy traditional defences. The international spread of infectious diseases from any country is an external danger from which state citizens need to be shielded through stronger systems of public health defence. Infectious diseases also threaten national security when deteriorating health trends in any one country lead to instability and social upheaval. Endemic infectious diseases are a particular security challenge as they resurge, because they behave in ways that can overwhelm social and public health infrastructures and cause demographic disparity. The emergence of AIDS and its rapid progression to endemicity convinced the world that a previously unknown pathogen can cause social and economic upheaval on a scale that threatens to destabilize whole regions.

Meeting challenges:

In developing countries, the destabilizing effect of AIDS, and other endemic diseases such as tuberculosis and malaria, is amplified by emerging and epidemic-prone diseases. Outbreaks and epidemics disrupt routine control programmes and health services, often for extended time periods, due to the extraordinary resources and logistics required for their containment. The dramatic interruption of trade, travel, and tourism that can follow news of an outbreak or epidemic thus places a further burden on public health systems in already fragile economies.

Conclusion (max 400 words):

Foreign policy agendas that aim to build a more secure world are increasingly including the emergence and resurgence of infectious diseases as a security challenge that needs to be addressed. They have global causes and consequences that can only be addressed through international global partnership, supported by strong national public health capacity. In April 2000, WHO launched the Global Outbreak Alert and Response Network (GOARN) as a partnership to keep the volatile microbial world under close surveillance and ensure that outbreaks are quickly detected and contained. This network of networks interlinks, in real time, over 110 existing networks that, together, posses much of the data, expertise and skills required to keep the international community alert to outbreaks and ready to respond. It was GOARN that detected and responded to the SARS outbreak in 2003, and it is GOARN that continues to watch over the current avian influenza pandemic threat.

GHF2006 – PS01 – Do Global Funds Really Facilitate Access to Health?

Session outline

Parallel session PS01, Wednesday, August 30 2006, 16:00-17:30, Room 3
Chair(s): Elisabeth Fee, Chief, History of Medication Division, National Library of Medicine, USA, Bernardino Fantini, Director, History of Medicine and Health Institute, Faculty of Medicine, University of Geneva, Switzerland
Summary: Numerous international funds have been set up in recent times to address global health challenges such as HIV, TB and malaria, in an effort to provide sustainable funding for selected diseases affecting billions of people in the poorer regions of the world. Despite impressive investments in terms of money and stakeholders' involvement at national and international levels, enabling the scaling up of specific health initiatives, the collective impact of these initiatives has sometimes created or exacerbated problems such as the poor coordination or duplication of programmes, heavy burdens on local health practitioners, variable degrees of country ownership, and a lack of alignment with country systems. Relying on the establishment of inclusive partnerships, financial institutions like the Global Fund to Fight AIDS, Tuberculosis, and Malaria do not take full responsibility for implementing funded programmes which require the active participation of partners in proposal development and realization (through Country Coordinating Mechanisms). One of the major reasons for the apparent ineffectiveness of global interventions is the historical weakness of the health systems of underdeveloped countries, which contribute to bottlenecks in the distribution and utilisation of funds.

  • What are the pros and cons of the global funds from different country perspectives?
  • In theory, the global funds programmes are to be continued and sustained in the long term by the countries themselves. Is this a reasonable expectation?
  • Is the money coming into the global funds? programmes (from the donors and also the recipient countries) new money, or is it simply being shifted from one health programme to another?
  • How can the funds best support equity, universal coverage, and sustained improvement in health systems? performance?
  • What are the key steps needed to implement the Paris declaration, with its guiding principles of ownership, harmonisation, alignment, results, and mutual accountability?

This round table session will debate the pros and cons of the ways the global funds work (or fail to work) in practice and try to answer the above questions.

 Panelist 1: Lola Dare, Executive Secretary, African Council for Sustainable Health Development, Nigeria
 Panelist 2: Marcos Cueto, Professor Principal, Universidad Peruana Cayetano Heredia, Peru
 Panelist 3: Suwit Wibulpolprasert, Ministry of Public Health Advisor, Ministry of Health, Thailand

Session report

Submitted by: Hassatou Conde (ICVolunteers); Contributors: Elise Magnenat (ICVolunteers)

Image: Viola Krebs, ICVolontaires.org

On the first day of the Geneva Health Forum, a roundtable took place on the subject of the efficiency of Global Funds in improving access to health for populations. The participants took a historical perspective on the efficiency of Global Funds programmes and recognized the importance of ensuring that all stake holders, including patients, community leaders and contributors to the fund, participate in its negotiation. "Global partnerships are increasing but results are missing", said Dr. Cueto, first panellist of the Symposium on Global Funds and Access to Health. The debate focused on the gap between the increasing number of global initiatives and expectations of local populations.

Dr. Marcos Cueto is a historian and a professor at the School of Public Health of the Universidad Peruana Cayetano-Heredia in Lima, Perú. His main focuses are the history of epidemic diseases and of public health in Latin America.

Dr. Cueto brought a historical perspective of international health in Latin America and discussed the Global Fund to Fight AIDS, Tuberculosis and Malaria. According to Dr. Cueto, a historical approach is essential for a better understanding of the present public health challenges. Dr. Cueto took the example of Malaria Eradication Campaigns and Primary Health Care Programmes set up during the 1950s and the 1970s in Latin America. He pointed out several drawbacks and shortcomings of the methods used, mostly related to the lack of communication between the major stakeholders and to the absence of adoption of the programmes by local actors. Most people in Least Developed Countries (LDCs) do not really see health system reforms as essential, he said, and this leads to misunderstanding between these populations and the decision takers.

Concerning the Global Fund fight against AIDS, Tuberculosis and Malaria, he noticed that the resources invested in this initiative are important and have a positive impact and he confirmed that the Global Fund represents a great opportunity for LDCs. But the question is: "Are we ready to catch this golden opportunity?"

Dr. Lola Dare, a community physician and medical epidemiologist from Nigeria, was the second panellist. In 2001 she was given an award by the African Regional Office of the World Health Organization for the 'Oriade Initiative', which aims to identify culturally sensitive and adaptive mechanisms for community co-financing and management.

Dr. Dare had a more critical perspective, highlighting the numerous constraints that Global Health Initiatives have to deal with, often leading to an absence of concrete results. Global Health Initiatives have been in existence since colonial times, but although "the goals change, the main issue of inequality in access to health remains", explained Dr. Dare. Hence, there seems to be a real problem as regards equality of access to health, as well as the increase in the number of initiatives.

Dr. Dare balanced her criticism by noting that the increase in Global Funds have also brought benefits, although often the receivers of the funds, local populations, are not always in a position to take advantage of them due to a lack of coordination.

Both panellists were in agreement on the question of the preparedness of countries to receive Global Funds and the necessity to align the objectives and programmes of Global Funds with country's priorities, policies and fiscal capabilities.

The participants of the Symposium agreed that one of the key goals for effective use of the Global Funds is to ensure access to health for local populations. Hence it is important that all stake holders participate in negotiations, including patients, community leaders and the contributors to Global Funds.

GHF2006 – PL03 – Public-Private Partnerships: Exploring the Framework

Session outline

Plenary session, Thursday, August 31 2006, 14:00-15:30
Chair(s): Louis J. Currat, Switzerland, Nick Drager, Switzerland
Health Impacts of Trade Agreements: A critical Reflection
Sisule F. Musungu, Acting Coordinator, Innovation, Access to Knowledge and Intellectual Property Programme (IAIPP), South Centre, Geneva, Switzerland
The Social Responsibility of the Private Sector and the Right to Health
Klaus Leisinger, Special Advisor on UN Global Compact to the UN Secretary General; Director, Novartis Foundation for Sustainable Development, Basel, Switzerland
Strengthening the Long-term Capacity of the Public Sector
Pascoal Mocumbi, European and Developing Countries Clinical Trial Partnership (EDCTP) High Representative, Mozambique
Public-Private Partnerships for Health
Roy Widdus, Global Health Futures Network, Geneva, Switzerland

Session Documents

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Session Report

Submitted by: Elise Magnenat (ICVolunteers); Contributors: Dr. Shibani Bandyopadhyay (ICVolonteers)
Image: Jorge Garbino, ICVolontaires.org

To tackle global health problems that disproportionately affect the poor, the skills and expertise of the private as well as the public sectors are needed; thus, Public and Private Partnerships (PPP's), which sharply increased in number between 1995 and 2005. As one of the speakers, Dr. Roy Widdus, said, "They can be seen as valuable 'social experiments' which achieve synergy through complementarity" and most of all "to which few, if any, realistic alternatives exist". The plenary session that took place this afternoon at the Geneva Forum comprehensively addressed the issues arising from PPPs.

Mr. S. F. Musungu is the Team Leader, Intellectual Property, Investment and Technology Transfer at the South Centre in Geneva. He is also Chairman of the Board of Directors of Health Action International - Africa (HAI Africa). Mr. Musungu, who has consulted for, and acted as an advisor to, various UN agencies, international organizations, non-governmental organizations and national governments, is the author of a number of publications and papers on intellectual property, trade, and human rights.

In his presentation about the health impacts of trade agreements, Mr. Musungu pointed out that in a globalized world; trade agreements have several health impacts. Indeed they are currently seen as the main framework for encouraging incentives as well as financing innovation in the health sector. They also provide a framework for the liberalization of health services and affect the provision of health-related services. Finally, they have a direct impact on pharmaceuticals and other health care products and equipment due to their role as tariff regulators. According to Mr. Musungu, PPP's are closely linked with trade agreements as they are shaped by them. However, even if PPP's can bring innovative solutions to health problems, they can also be the origin of public policy failure.

The speaker expressed his concerns about the current situation where there are no appropriate funding and incentive mechanisms for the creation of health products for the diseases that disproportionately affect developing countries. Moreover, even in cases where there are solutions, there is a tragic lack of access because of the absence of global mechanisms that seek to address the twin issues of innovation funding and access in an appropriate manner. Mr. Musungu then mentioned the World Health Assembly resolution 59.24, May 2006, which calls for the establishment of a global strategy and plan of action. He affirmed that this could be a critical opportunity to address the weaknesses and negative impacts of key trade agreements. But he concluded his presentation by posing the question to the healthcare community whether they would indeed be able to work towards this.

Professor K. M. Leisinger has been President and Chief Executive Officer of the Novartis Foundation for Sustainable Development since 2002. In 2005, he was appointed by the United Nations Secretary-General Kofi Annan as 'Special Advisor on the Global Compact'. In addition to these positions, he teaches and conducts research as Professor of Sociology at the University of Basel. He also serves as advisor to various national and international organizations dealing with sustainable development.

Prof. Leisinger's presentation raised the issue of corporate responsibility in the pharmaceutical industry and the right to health. Recognizing that responsible business can be part of the solution to the challenges of globalization, the Global Compact has been created to promote responsible corporate citizenship. In this way, the private sector - in partnership with other social actors - can help realize a more sustainable and inclusive global economy. Thus, Prof. Leisinger outlined various elements of an enlightened corporate business including organizing debates with other stakeholders, developing and implementing corporate guidelines and communicating with the public. He also emphasized the risks linked with corporate responsibility which are mainly due to the over-simplification of complex issues and the shift of national responsibilities away from the primary duty bearers, thereby providing an excuse to irresponsible governments.

Dr. P. Mocumbi was the Prime Minister of Mozambique from 1994 until 2004. He is representing the Medicines for Malaria Venture and is High Representative of the European and Developing Countries Clinical Trials Partnership (EDCTP). As a minister of health, he was responsible for the successful creation of the nurses' 'maternal-infantile health' basic level course and has wide experience of the role of the State in health provision.

Dr. Mocumbi's speech focused on strengthening the long-term capacity of the public sector. He reminded us that despite technical advances and repeated commitments from governments and international organizations, we are witnessing gross inequities across the world in the field of health and access to health. He insisted on the close relationship between poverty, security and access to health, declaring that "AIDS is a global security threat because of its impact on governance". Dr. Mocumbi went on to emphasize the challenges now facing the Public sector: financing of health systems, organization and structure of the healthcare system and finally human resources for health crises. All nations are expected to plan and lead the implementation of the basics: building health systems, providing affordable education and promoting gender equality and universal protection of human rights. Creativity and innovation are essential to find healthcare financing to address under-funded, poorly managed public health sectors. Additionally, exploring complementary financing to strengthen community participation and ownership could be seen as a key to improving health partnerships.

Dr. R. Widdus presently serves as Project Manager of the Initiative on Public-Private Partnership for Health at the Global Forum for Health Research. From 1995 to January 2000 he was Coordinator of the Secretariat to the Children's Vaccine Initiative. He has experience in a variety of work settings including research, teaching, biotechnology and pharmaceutical industries, and policy development for science and health in government and international agencies.

The term 'public-private partnership' (PPP) is applied to a diverse range of ventures designed to improve access of poor populations to particular health products or services, said Dr. Widdus. PPP's came into being to fill the gap left by independent actors, mostly due to market inefficiencies, lack of government resources in poorer countries and insufficiency of international aid. PPP's include many actors, all coming either from the public sector, civil society or the for-profit sector. Each of them has a specific role and benefit which needs to be clearly identified but many possible collaborative relationships can occur between public and private sectors. Therefore Dr. Widdus split PPP's into different categories with regards to their strategy. The three most relevant types are: product development partnerships, 'Access' partnerships and global coordination or funding mechanisms. The speaker insisted on the need to segment PPP's as a means to address the issue better and to find the most effective solution for each problem.

GHF2006 – PS17 Challenges in Long-Term Drug Delivery (HIV & TB)

Session Outline

Parallel session, Friday, September 1 2006, 11:00-12:30
Chair(s): Bernard Hirschel, Switzerland, Alexandra Calmy, Switzerland
Sustainable Financing and HIV, Malaria, TB Control
Michel Kazatchkine, Ambassador on HIV/AIDS and Transmissible Diseases; Director, National Agency for Research on AIDS, Paris, France 
Long-Term Challenges for ARV Programmes on the African Continent: Experience from Southern Africa 
Eric Goemaere, Médecins sans frontières (MSF) South Africa, Head of Mission, Cape Town, South Africa
The New Stop TB Strategy
Mario Raviglione, Stop TB Department, World Health Organization, Geneva, Switzerland 

Session Documents

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Session Report

Submitted by: Elise Magnenat (ICVolunteers); Contributors: Martin Elling (ICVolunteers), Milena Lawrence-Samuel (ICVolunteers), Tatjana Schwabe (ICVolunteers)
"TB control is a marathon, not a sprint!" Image: Viola Krebs, ICVolunteers.org

The three speakers of this session all emphasized the increasing negative impact of diseases like HIV/AIDS, tuberculosis (TB) and malaria on economic and social development in the world today. As Mr. Kazatchkine said: "The health sector [...] was originally seen as a non-profitable source of expenditure, is now considered as a factor and a necessary investment for development". Indeed, the benefits of preventing and treating HIV/AIDS, TB and malaria outweigh the costs caused by such diseases. Other topics discussed included sources of funding for treatment and prevention of these diseases, as well as problems in providing efficient health care for victims in the developing world.

Mr. Michel Kazatchkine, the French Ambassador for HIV/AIDS and Transmissible Diseases and the Director of the National Agency for Research on AIDS in France opened the symposium by reminding the audience that HIV, TB and malaria are "by far the leading causes of ill-health and premature death in Africa". Their impact on development had led to a shift in perception of health. Whereas formerly, health was seen as a consequence of development, it is today considered as a factor of economic growth. This observation has become particularly evident with AIDS which has been a catalyst to bring link between poverty and access to health on international agenda. Mr. Kazatchkine insisted that it was essential to shift financing from an emergency mode to building sustainability by drawing on national resources of affected countries as well as external funding. In the latter category, Official Development Aid (ODA) clearly represents the most important contribution, with a significant increase over the last years. However, the increase of money addressed to the health sector has been smaller compared to education or governance, although the number of people affected by disease is increasing and treatments, which need to evolve with the target disease, become more and more costly. Sustainability is also difficult to achieve because governments contribution to ODA is based on their national budget and changes yearly. Another source of external funding is what Mr. Kazatchkine called "Innovative sources of funding" such as debt conversion or the International Finance Facility for Immunisation (IFFIM), proposed by the International Financing Facility (IFF). He went on to present in more in detail the air ticket levy to fund the purchase of drugs against AIDS, Malaria and TB, introduced by five countries including France since July 2006. This new tax was instigated to raise money from people who benefit from globalization and to redistribute it to people who do not. The funds raised do not transit through France's national budget. Mr. Kazatchkine considered this project, together with other alternative initiatives, a necessary condition to fill in the huge financial gap for 2006.

Mr. Eric Goemaere of Médecins Sans Frontières (MSF) in South Africa provided a field perspective of long term challenges of anti-retroviral treatment (ARV) programmes against HIV/AIDS in Africa. The minimal objective of MSF is to offer an average of 10 years of survival treatment to AIDS victims. To attain these objectives, several issues have to be addressed. Firstly, Mr. Goemaere highlighted that the HIV/AIDS problem has no "quick fix", but is a long-term issue requiring long-term commitment from both the patients and care-givers. Although focus has been placed on prevention, this should not diminish the efforts to treat the millions of HIV/AIDS-diagnosed victims. Another concern is the financial cost of the HIV/AIDS treatment. For most of the HIV/AIDS infected people from developing countries, 40-60% of their income would have to be devoted exclusively to ARC treatments. As Mr. Bill Gates recently pointed out at the XIV International AIDS Conference in Toronto, "such a financial effort might not be sustainable if there is no improvement in the reduction of new infection rates", a sentence that could be interpreted as an early sign of donor's fatigue. There has been no major reduction in drug prices for the last two years despite enormous increases in drug consumption. Moreover, there is a need for cheaper and more user-friendly second line drugs, which are 5 times more expensive that first line drugs. The prerequisites for long term adherence to ARV treatment are free access to ARV, including user fees and collateral costs such as lab monitoring; peripheral rather than central approach; sufficient investment into human resources, in light of the recent high migration of nurses particularly to the UK and the USA; and counselling, community networking and peer support.

Some concern has been raised that "ARV programmes will pull away from the few resources available for primary health care service (PHCS) levels. Furthermore, the gap must be bridged between TB and HIV services, two obviously interlinked diseases. Mr. Goemaere stressed that broad health-care systems, patients, funding, and governments all have struggles that need fixing. He emphasized the current lack of strong political leaders, who have a key role as catalysts in changing public opinion and who should not be replaced by non-elected leaders.

Mr. Mario Raviglione, who represented the Stop TB initiative of the WHO based here in Geneva, focused his presentation exclusively on tuberculosis. He summarized the current burden of tuberculosis, a disease of poverty, whose control is a human right, a public good and a potential "quick-win" of the Millennium Development Goals (MDGs). Because TB is the biggest cause of death from a curable or preventable disease of today, Mr. Raviglione compared tuberculosis to "a SARS epidemic every day". Mr. Raviglione also stressed the link between TB and HIV/AIDS which are co-epidemics. TB is the first cause of HIV-related deaths in the world, causing more than 500,000 deaths per year. Moreover, the prevalence of multiple drug resistant (MDR) and extremely drug resistant (XDR) tuberculosis is on the rise. The economic impact of TB can be seen in both the macro- and micro-economic fields. Cost of diagnosis and treatment is a huge concern for those directly affected and the major funding is required for large-scale mobilization of health care (clinics, hospitals with adequate treatment). There is notably a loss in economic productivity due to the 1.7 million annual deaths caused by TB, with most of the victims being economically productive adults. The regions most affected by TB, and where effort must be focused in order to attain the MDGs, are Eastern Europe and particularly Africa. The 2005 World Health Assembly set the aim to detect at least 70% of infectious TB cases and to successfully treat at least 85% of the detected cases. Current worldwide figures are respectively 53% and 82%.

Mr. Raviglione presented the Stop TB initiative which aim at decreasing the global burden of tuberculosis by 2015 in line with the MDG and Stop TB Partnerships targets. The strategy includes the following main points: pursue and expand high quality DOTs; address TB/HIV-AIDS, MDR-TB and other challenges; contribute to health system strengthening; engage all care-providers; empower people with tuberculosis and communities; enable and promote research. He concluded, "TB control is a marathon, not a sprint!"