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2 Models for Multi-Sectoral Engagement in Global Health: Challenges and Opportunities Highlights and Main Points Made by Peter Singer â¢ sectors working in global health have the same principal value proposition, All which is to save and improve lives. â¢ There is opportunity to develop models of cross-sector engagement through precision public healthâan evolving field where data and information enable targeted solutions to address global health problems. â¢ Lifesaving products have been developed through innovation-focused partner- ships, which have provided sustainable platforms for scaling and shared-risk financing options. â¢ The most successful models and partnerships are those that build trust be- cause the fundamental challenge of multi-sectoral engagement is establishing trust between sectors. â¢ The SDGs, particularly SDG 17, promote an enabling environment that facili- tates trust and collaboration across sectors. â¢ There is increasing mutual interest among sectors to shape health-oriented consumer demand. â¢ Among partners, deeply entrenched ideological positions can create percep- tions that do not facilitate the dialogue and partnerships necessary to pursue opportunities and achieve innovations that are possible only through collective action. 7 PREPUBLICATION COPYâUncorrected Proofs
8 VALUE PROPOSITION AND INNOVATIVE MODELS Participating via webcast, Peter Singer, special advisor to Tedros Adhanom Ghebreyesus, the current director-general of WHO, explained that he would speak from his perspective as a special advisor and from his own experiences. Organizing his presentation around the workshopâs objectives, he provided definitions and examples of value propositions, partner-engagement models established by WHO, and ways that innova- tion and innovative finance can foster the development of such models. He also defined the greatest challenge to multi-sector engagement. Singer then participated in an audience discussion. This chapter summarizes Singerâs presentation and the subsequent discussion session with work- shop participants. VALUE PROPOSITION AND MODELS According to Singer, all sectors have the same principal value propo- sition, which is to save and improve lives. Partnerships across sectors, as formalized through SDG 17,1 are needed to remediate challenges faced in global health because the issues are too extensive to be solved by one sector alone. Additionally, efforts to save and improve lives require finan- cially sustainable or profitable models in order to be successful. With this focus on models, Singer explained that WHO recently devel- oped an intentionally ambitious new strategy to engage partners and member states. WHOâs 13th General Programme of Work is a 5-year initiative (2019â2023) that includes the âtriple billion goalâ of achieving â1 billion more people benefiting from universal health coverage (UHC),â â1 billion more people better protected from health emergencies,â and â1 billion more people enjoying better health and wellbeingâ (WHO, 2018a). Singer noted that multi-sectoral interventions will be used to achieve the targets. Better protection from health emergencies, better health and well- being, and greater multi-sectoral interventions are essential UHC goals, Singer explained. Models to reinforce these goals include WHOâs work to improve access to medicines through facilitating their prequalification, which results in considerable drops in their pricingâparticularly when more than one medicine is prequalified. In another model, WHO spurs the demand for products that meet certain technical quality standards through developing essential medicines and essential diagnostics lists, which are based on expert opinion. WHOâs Pandemic Influenza Prepared- ness Framework is another model that the organization uses to address the goal of reducing health emergencies. After determining which strains 1â SDG 17âs full citation: âStrengthen the means of implementation and revitalize the global partnership for sustainable developmentâ (UN, 2019c). PREPUBLICATION COPYâUncorrected Proofs
MODELS FOR MULTI-SECTORAL ENGAGEMENT IN GLOBAL HEALTH 9 of influenza vaccine will likely be needed for the next flu season, the framework supplies those strains to manufacturers who then produce the upcoming seasonâs vaccine. Another model focused on health and well-being is WHOâs Frame- work Convention on Tobacco Control, which, Singer noted, is an interna- tional treaty that enables and motivates member countries to enact laws and branding (such as taxes on tobacco products and targeted anti-tobacco product package labeling) that promote tobacco control. Another recent WHO initiative focuses on eliminating trans fats through working with the food industry to reformulate products. Understandably, consumer demand plays a strong role in defining the bounds of this intervention. Singer noted that WHO works with the food industry on similar models, which involve an interplay between regulation, consumer demand, and product reformulation, that are related to obesity prevention. Singer believes WHO is willing to work with all sectors as part of its strategy to impact people at the country level through efforts governed by the Framework for Engagement with Non-State Actors (FENSA); how- ever, he noted there are also prohibitive models that leave out indus- try involvement. For example, WHO does not engage directly with the tobacco industry to reduce smoking rates; instead, it works with govern- ments to establish anti-smoking initiatives. Innovation and Innovation Finance For Singer, data, innovation, and innovative finance represent promis- ing areas in which to develop models that enable cross-sector engagement for improving global health. For example, precision public healthâan evolving field where data and information enable targeted solutions to address global health problemsâprovides opportunities to develop such models. Additionally, lifesaving products have been developed through partnerships focused on innovation. Inhaled oxytocin, for example, was developed as part of the Saving Lives at Birth initiative, a collaboration between the global health care company GlaxoSmithKline, Monash Uni- versity, and various other groups. This product is made by putting oxy- tocin, which stops maternal hemorrhaging, in an asthma inhaler so that it does not require refrigeration or delivery by injection. Other examples of health-focused innovations include the augmented infant resuscitator developed by Philips: a bag and mask are placed over a newbornâs head to show resuscitation quality through green, yellow, and red indicators. This product both enhances the quality of clinical care and reduces newborn fatalities. Singer also mentioned the Odon device, used PREPUBLICATION COPYâUncorrected Proofs
10 VALUE PROPOSITION AND INNOVATIVE MODELS for assisted vaginal delivery in delayed labor, as another innovation from Becton, Dickinson and Company. Singer noted that the device represents one of the first innovations in assisted vaginal delivery in 200 years. What these examples have in common, Singer clarified, is that their associated companies and partners are providing sustainable platforms for scaling. Their public-sector partners, especially their financial partners, are reducing hurdles and sharing risks associated with the products by providing options such as repayable finance. If the product is successful, the public sector and the company will share the return. If the product is unsuccessful, the public sector and the financial partner will have already lowered the financial risk at the front end. These public-sector partners also bring their strategic insights and networks to domestic governments, which are then able to scale the products. As previously mentioned, partnerships across sectors are needed to remediate global health challenges that are too extensive to be solved by one sector alone and such efforts require finan- cially sustainable or profitable models in order to be successful. The Fundamental Challenge Singer emphasized that the most successful models and partnerships are those that build trust because the fundamental challenge of multi- sectoral engagement is to establish trust between sectors. Another chal- lenge is to establish the ability for sectors to collaborate. As the number of lives that are saved and improved through partnerships rooted in trust increase, future demand for enhanced partnerships and partnership mod- els will also increase. The SDGs, particularly SDG 17, promote an enabling environment that facilitates trust and collaboration across sectors. Singer proposed the equation SDG 17/Partnership + Impact = Trust as a way to frame the essential elements needed to catalyze trust. DISCUSSION Scott Ratzan, senior fellow at the Harvard Kennedy School, noted that both he and Singer, at separate times, had served as co-chair of WHOâs Innovation Working Group. Ratzan wanted to know how a model such as the working group could facilitate development in the areas Singer men- tioned, including innovative financing, digital technology, and marketing for public health. Singer explained that the Innovation Working Group is a platform associated with the United Nations Secretary Generalâs Office, and it introduces innovation to the Every Woman Every Child initiative. The goal of the working group is to scale 20 innovations by 2020. The group PREPUBLICATION COPYâUncorrected Proofs
MODELS FOR MULTI-SECTORAL ENGAGEMENT IN GLOBAL HEALTH 11 focuses on researching and evaluating innovations that are agnostic to their source. It also tries to entertain private capital to demonstrate an evaluative system for innovations linked to SDGs across different funders and to show that such a system can be largely successful. Still, Singer noted the difficulties associated with developing a model to obtain tril- lions of dollars in private capital. Singerâs efforts with the Innovation Working Group led to a simple idea: identify the top 10, 15, and 20 innovations that are ready to scale; evaluate them; look at their application; link them to governments; and then work to scale them. This is something that he believed WHO could potentially do because WHO plays an important role, especially for domestic governments, in scaling innovations. A successful example is the Meningitis Vaccine Project in North Africa, an initiative by WHO, PATH, the Bill & Melinda Gates Foundation, and the Serum Institute. According to Singer, scaling even a small number of innovations can make a big dif- ference in global health. Regarding consumer demand, Singer thought there was increas- ing mutual interest among sectors to shape health-oriented consumer demand because shareholders prevent companies from reformulating products unless consumer preference shifts toward such new products. Clarion Johnson with ExxonMobil probed Singer about what issues concern him most in the next 2 or 3 years. Singer responded that he is concerned about ideology, or a lack of âopenness to engage, to learn, and in a humble way, to serve the people weâre all interested in.â He believed that ideology on all sides can lead sectors to mischaracterize each other. Singer noted that deeply entrenched ideological positions cause people to start from perceptions that do not facilitate the dialogue and partner- ships necessary to pursue opportunities and achieve innovations that are possible only through collective action. Singerâs concerns about ideology are related to interactions between the public and private sectors, which he considers necessary to facilitate dialogue in order to grow innovation. For example, access to a specific geographic area may be needed to target malaria solutions to the exact location where cases occur. In this instance, the public and private sec- tors could work together in order to make that area safe and accessible for health interventions. He also emphasized the importance of demon- strating proof of concept and of building partner trust. Parts of WHOâs new mission are to promote health and to serve the vulnerable, but these cannot be accomplished without dialogue. Singer said, âWhat you see in WHO now, and certainly with Dr. Tedros, is a humility and an open- ness to engage and to listen, and then to partner under those rules of engagement.â PREPUBLICATION COPYâUncorrected Proofs
12 VALUE PROPOSITION AND INNOVATIVE MODELS Johnson asked Singer how he sees WHOâs role changing as popula- tions shift and people move from the country to cities. Singer responded that this population shift âimplicates all kinds of health shiftsâ and points to the important role of subnational and municipal governments in these transitions. WHO and its partners have some city-level activities, such as the Healthy Cities Network and the Global Network for Age-Friendly Cities and Communities, but Singer noted he has not yet seen an entity pull all of the activities together across schematics and sectors in order to use the platform of cities to deliver health. He saw an opportunity to look more systematically at a health issue, such as aging, noncommunicable diseases (NCDs), air pollution, or obesity, at the municipal level. PREPUBLICATION COPYâUncorrected Proofs