Through panel discussions that were followed by roundtable discussions facilitated by small groups, the first full session of the workshop explored assumptions about industry’s value proposition for global health engagement as well as the value proposition for other sectors to engage with industry (see Box 4-1 for the session objectives). The panel discussions analyzed reasons for private-sector engagement; explored examples of the value proposition in private-sector involvement and examples of shared value in both NGO and industry partnering; examined how private-sector business opportunities can change both value proposition and partnership engagement; and looked at partnership risks and challenges through the lens of shared value. The small table discussion session that followed focused on barriers and enablers to PPPs based on value proposition and multi-sectoral engagement. This chapter summarizes these panel and roundtable discussions.
Panel moderator Wendy Taylor, fellow and senior advisor with The Rockefeller Foundation, noted that over the past decade, partnerships have evolved, and partners have looked for ways to create value. While previously working at the U.S. Agency for International Development (USAID), Taylor was frequently involved in conversations about increased and aligned incentives for private-sector engagement, which the USAID administration recognized needed to be leveraged in order to achieve its development objectives. Taylor explained that the last four administrators
across three different administrations all emphasized engaging the private sector to pursue USAID’s development agenda, and she noted there was reason to believe that the current administrator did, as well.
Taylor said there had been a recognition from the public sector that it can no longer take on development objectives by itself, and it needs private-sector involvement to achieve its development goals. Although the flow of money into countries previously issued largely from the public sector, public funding now forms only 9 percent of the total distribution; the majority comes from the private sector.
Additionally, noted Taylor, there is a need to look beyond traditional models of partnering to new models of development, partnership, and engagement with the private sector. The private sector has changed its reasons for engaging—in addition to corporate social responsibility, health-related market opportunities have increased because LMICs face unprecedented economic expansion. Taylor noted that the pharmaceutical industry’s spending in Africa, for example, will reach $45 billion by 2020. Other sectors are also playing a significant role in these growing markets and are determining how to expand market opportunities to create reasons for engaging. Taylor highlighted that the reasons NGOs enter partnerships include bringing new skills and technology to a region, building capacity, and developing ways to use data to solve problems. Taylor concluded by asking each panelist to provide examples of and context on how and why their organizations are engaged in global health or global health partnerships.
Colatrella explained that Merck’s mission is to discover and develop important medicines to help address the world’s greatest health challenges. Engagement in global health and public health in under-resourced communities is an important part of this mission, and it forms a way to demonstrate their commitment to corporate responsibility. Merck also recognizes the important role that the private sector plays in achieving the SDGs.
According to Colatrella, Merck engages through traditional philanthropy or social investment, initiatives for shared value or for mutually reinforcing social and business value, and commercial models. Such engagements allow the company to bring more core business expertise to the table. Additionally, when looking at public health challenges, the value proposition is often influenced by or influences the type of model through which a company engages.
Colatrella emphasized the importance of relationships—particularly those with NGO partners that have strong connections at the local level. Such relationships help the company build alliances and enable more engagement in policy discussions. Colatrella also emphasized the impor-
tance of shared value in raising Merck’s awareness of the ways it can parlay its products and expertise into the development of new markets or the expansion of existing ones. Through partnerships, Merck also learns best practices and innovative ways to collaborate, and their global health engagements help the company attract new talent and develop and retain existing staff.
Next, Shawn Dolley, director of Life Sciences and Health Care at the Cloud-based software company Cloudera, described why “Big Tech” is interested in global health engagement. He clarified that Big Tech includes companies such as Amazon, Apple, Cloudera, Facebook, Google, Intel, Microsoft, SAP, and other multi-billion-dollar software companies. Dolley has worked at some of these companies and noted that his comments would be an amalgam or an aggregate of lessons learned and value propositions drawn from these businesses.
The tech industry is often asked to work with other sectors, which, Dolley noted, was not the case two decades ago. Technologies such as phones, apps, and self-driving cars, and the skills introduced by the companies that make them, have catalyzed a renewed interest in tech industry involvement.
Dolley discussed a small, aggregated set of reasons for tech industry engagement in public health and said that many tech companies have independent ideologies that do not embrace outside guidance about how they need to conduct business. Still, there is growing recognition within the tech industry that it cannot work in a vacuum, and it needs to establish partnerships—particularly because it has encountered constraints in data access and use. One strategy for breaking down these independent ideologies is greater exposure to other sectors; the tech industry often presents ideas that are big but unworkable, and learning the limits of certain ideas (e.g., access to data, money, or community technologies such as stoplights) may make the company listen to the needs of other sectors.
Bruce Wilkinson, CEO with the Catholic Medical Mission Board (CMMB), described CMMB as a 108-year-old, Jesuit-inspired global health organization focused on the most vulnerable populations—including women and children. CMMB works on health systems strengthening by engaging partners long term to build their capacity to respond to a community’s needs. Such capacity building is focused on changing health-seeking behaviors in the community. To accomplish this mission, CMMB uses a strong volunteer base to help distribute medicines and implement infectious and chronic disease programs. One area of special focus is increasing access to health services for women in extreme poverty, a goal Wilkinson believes could be better achieved through more private-sector involvement.
During the 2000s, while in a prior role, Wilkinson traveled to Africa with Tommy Thompson and a group of pharmaceutical industry CEOs. At the time, there was an understanding that pharmaceutical-industry engagement was necessary in The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) launch. Through this experience, Wilkinson realized the importance of the private sector and identified a need for better engagement with it. Wilkinson argued that although civil society organizations are known for having strong relationships with communities, companies may actually have stronger connections and more data because community representatives are also often company clients.
Wilkinson suggested there needs to be increased sharing of information between civil society organizations, governments, and the private sector to better sustain health interventions and to improve people’s health. In particular, civil society organizations and the private sector share an interest in understanding what leads to better long-term, health-seeking behavior outcomes.
Taylor prompted the panelists to consider examples that further illustrated the value proposition in private-sector involvement. Colatrella then described Merck’s Mectizan Donation Program. Although it is a traditional philanthropy program, the Mectizan Donation Program was one of the first PPPs of its kind when it began 31 years ago. The program is a broad partnership of public health experts, NGOs, governments, WHO, the World Bank, and others that were brought together to address two diseases—river blindness (onchocerciasis) and lymphatic filariasis—found in sub-Saharan Africa, parts of Latin America, and Yemen.
Colatrella explained that Merck began this initiative without much consideration of its value proposition beyond acknowledging they had a safe, effective product to address these diseases. Each partner, however, had its own unique value proposition and contribution to the initiative. This was important for ensuring the program’s sustainability. The establishment of the Mectizan Donation Program also created the opportunity for Merck to develop long-standing partnerships with WHO, the World Bank, and a broad set of NGOs. These partnerships allowed Merck to work with these organizations in other areas of corporate responsibility and commercial business.
Regarding the workforce benefits of engagement that Colatrella highlighted in her opening remarks, she noted anecdotally that several Merck employees have said that they chose to work at the company because of its engagement in global health. Merck also has a global health fellow-
ship program that allows highly talented employees to spend 3 months in the field with a participating NGO that determines what it needs from the fellows (e.g., financial skills, research, or regulatory capabilities). The fellowship program has a specific value proposition: Merck fellows help build capacity in their areas of focus, and, after the fellowship, they bring their learnings back to the company. As a result, the company gains new knowledge and expertise in areas it otherwise may not have.
Next, Wilkinson was asked to describe examples of where he has seen value in partnering for both NGOs and industry. In 2004, Wilkinson travelled to Zambia to lead a large national HIV/AIDS program. At the time, the HIV/AIDS epidemic in Zambia was so severe that, according to Wilkinson, as many as one in six children were orphaned, and the workforce was adversely affected. There was concern that if the problem was not addressed in a timely manner, it could lead to outbreaks of the “triple threats,” malaria, TB, and HIV, as well as to civil wars similar to those that occurred in Sierra Leone and Liberia the decade before—conflicts that largely involved youth who had been mobilized to fight.
Wilkinson explained that the program was initially funded with a $30 million PEPFAR commitment, but this increased to $180 million within 5 years through further investments from PEPFAR and from other foundations and corporations. As a result, the program was able to partner with roughly 250 organizations; train 23,000 community caregivers to care for 285,000 children who were orphaned as a result of HIV; and enable approximately 75,000 people living with HIV to receive early treatment. The initiative was successful in the long term because people on the ground were willing to both choose health-seeking behaviors and to contribute to their communities.
Partners, Wilkinson emphasized, were also important for achieving specific goals. World Bicycle Relief, for example, donated 25,000 bicycles for caregivers to use as transportation, and the SRAM Corporation set up a system to build quality bicycles in Africa to facilitate the initiative. Hasbro donated 240,000 toys and other gifts to provide emotional support for affected children. Vestergaard provided 1.2 million insecticide-treated bed nets. McKesson provided 50,000 medical supply kits for caregivers. Six million children were dewormed, and the Zambian Ministry of Health offered vitamin A supplementation through school systems every 6 months. The U.S. National Football League provided extra merchandise to caregivers for distribution through their networks, and Pearson provided new educational materials. The program was also integrated with the government by placing advisors in government ministries to shape child-related policy. Wilkinson noted that through this intervention, more than 500,000 people were tested for HIV, and by 2007, HIV/AIDS testing
was occurring within households. A rapid diagnostic test for malaria was also introduced at the household level by 2005.
Taylor then asked the panelists how considerations regarding partnerships differ when engagement can lead to private-sector business opportunities that create competitive advantages—how do such opportunities change the value proposition and the way people think about partnering? Dolley responded that Big Tech’s first consideration is the likelihood of project success. Additionally, some Big Tech companies find it easier to engage in opportunities where the market is zero or approaches zero because it is outside of the commercial business model. Ideal situations occur when a market with zero opportunity intersects with a CEO’s personal interest and with a subject-matter expert or someone who can engage the community. When market opportunity exists, completely different sets of stakeholders are involved, and they cause opportunities to move in entirely different directions.
Dolley also explained how Cloudera uses technology-enabled precision public health; the company invests in an institution that uses satellite imagery to help manually curate maps that identify the locations of off-grid villages with potential vaccination needs. Through this initiative, the company gains technology-derived knowledge that they can use to expand public health interventions in the future.
Colatrella agreed with Dolley: a shared-value approach involves a different value proposition with potentially different partners, including more non-traditional partners. She noted that the ability to contribute to a cause in a way that has potential business benefit is appealing for many reasons—including its likelihood of sustainability. Merck, for example, entered into a partnership with a financing institution a few years ago to help under-resourced communities in India afford hepatitis C medicine. The micro-financing initiative provided funding to cover upfront medication costs, and Merck paid the interest on the loans. This enabled more people to access the medication than what would have been possible through standard financing mechanisms. It also enabled Merck to access a previously unreachable market.
Taylor next asked Wilkinson to describe partnership risks and challenges through the lens of shared value. Wilkinson explained that he views successful partnerships as those that involve more than just government and international organizations. He described his experience as a board member of Partners in Food Solutions, an organization that includes representatives from Ardent Mills, Buhler, Cargill, DSM, General Mills, and Hershey—agricultural businesses stationed in Holland, Switzerland, and the United States. The organization’s goal was to partner its representatives with small- to medium-sized African agricultural busi-
nesses to help them solve problems specific to the food industry. These issues included shelf life, nutritional content, sourcing, and milling.
Wilkinson said the program successfully supported 568 small- to medium-sized African businesses, and that support, in turn, resulted in new markets and growth for some of the supporting companies. Importantly, the private sector gave its knowledge of transferrable skills to local businesses, which led to a homegrown appreciation of market and business opportunities. This encouraged viable, well-managed African businesses—many of which are minority owned. Wilkinson noted that partnerships such as these represent shared value. He also explained that many different models, such as the capacities developed in the Catholic Health Association, can be applied to low-resource, low-income settings. Transferring this knowledge can lead to a deeper understanding of market and business opportunities.
Taylor added that partnerships can evolve over time and that although many involve multiple stakeholders from different sectors, she wanted to focus on how to partner stakeholders from the same sector when they share an interest in solving a particular problem. Taylor asked the panelists to comment on potential branding challenges when engaging partners.
Colatrella responded that, years ago, Merck wanted to be the only company, or the only company in its industry, engaged in a certain initiative. There is now an appreciation that including additional partners and companies from the same industry or from other industries can reduce risks, burdens, and costs and can increase innovation, impact, and scale. For Merck, the benefits of partnering—including increased potential for scale and impact—typically outweigh concerns regarding branding. Colatrella noted that Merck’s work with 14 companies, as part of the Gates Global Health Roundtable, exemplifies this idea.
Dolley also acknowledged that risk mitigation is an important impetus for partnerships. He provided an example of an initiative that involved six large pharmaceutical organizations that were surprisingly collaborative—as long as all conversations were kept private. Dolley noted that when several large companies in an industry agree to a partnership, pressure is created for others to join so they are not excluded from an industry-wide initiative.
Gabriella Morris from UNICEF asked how, in terms of shared value, a company’s considerations about whether to join a collaborative might be shaped if the potential partner were a foundation. Colatrella responded
that Merck considers large foundations, such as the Gates Foundation, to be important partners that contribute both financing and expertise. She clarified that anything funded through the Merck Foundation needs to be 100 percent charitable, and therefore, shared-value partnerships are not executed through the foundation. Colatrella, however, saw opportunities for larger foundations and NGOs to get involved in the shared-value arena.
Dolley noted that UNICEF’s Innovation Labs have created technology around data lakes that are adaptive to epidemic scenarios. In this instance, the risk to Big Tech is simply whether its help would be needed. Dolley noted that Big Tech wants to be invited to participate in partnerships more often.
John Monahan, senior fellow at the McCourt School of Public Policy and senior advisor to the president at Georgetown University, noted a lesson learned from the session: for a partnership to work, all partners need to understand how each partner defines the value proposition. He asked panelists for their perspectives on whether partnerships are more sustainable in situations where shared value is transparent and has been negotiated. Colatrella responded that she has never had a conversation with potential partners about value proposition specifically, but potential partners do describe why they want to collaborate. She noted that increased open, honest communication might be beneficial; her company has experienced situations in which its expectations for a partnership were not met and situations in which its expectations were exceeded. She suggested it would be helpful to understand from partners why they engage.
Wilkinson added that good initial questions to ask potential partners include how they define success and how they would like to measure it. The communication strategy could then focus on meeting those benchmarks. He also suggested ensuring that credit is given to all partners and promoting transparency. He noted that this can be complicated because each partner is bound by their organization’s rules around branding. Wilkinson emphasized the importance of establishing such complex dialogue as early as possible.
Taylor asked whether companies have their own internal success metrics in situations where partnerships have shared metrics for success. Colatrella acknowledged that Merck does not always focus on metrics but instead considers best practices and guidance when assessing and demonstrating impact—particularly with their social investments. She believes impact is easier to demonstrate with a commercial or shared-value model because partnerships are likely to have business or market targets. Dolley added that another metric for success could be introductions to or
relationships with people who could provide potential future business opportunities that would be otherwise unavailable.
Wiweka Kaszubska with the Medicines for Malaria Venture (MMV) asked the final question of the session: How willing is industry to engage in research and development (R&D) projects rather than to access projects with easier and more visible targets? Colatrella responded that Merck is increasingly involved with both access and R&D initiatives. Merck has made its compound libraries available to various groups as a way to expand the pool of expertise and the research that can be conducted. However, Colatrella noted a challenge: Companies often focus on areas where they have the most expertise and can develop an innovative product. As a result, they sometimes have difficulty prioritizing where resource investment is needed and determining whether to establish an R&D partnership.
Kumar then noted a general trend toward increased investment in R&D. For example, Johnson & Johnson has an entire team focused on R&D for its global health portfolio, which includes TB, HIV, vaccines, dengue, and NCDs. She also highlighted that R&D represents another opportunity for PPPs to collaborate and that she believes conversations are taking place between R&D leaders in industry and the public sector.
In closing, Taylor asked participants to identify any additional takeaways from the value proposition discussion. Wilkinson suggested making sure, before entering into a partnership, that partners love what they will be doing. Dolley suggested inviting Big Tech to global health conversations more often. Colatrella noted the importance of recognizing the value that the private sector can bring to public health.
SMALL TABLE DISCUSSIONS: INCENTIVES AND BARRIERS FOR ENGAGING IN GLOBAL HEALTH THROUGH MULTI-SECTORAL MODELS
Kumar noted the small table discussion session would focus on barriers and enablers to PPPs based on value proposition and on multi-sectoral engagement. Participants were asked to discuss two questions (see Box 4-2) for 20 minutes in small groups and then to reconvene to share their perspectives with the audience.
Mary Lou Valdez, associate commissioner for diplomacy and partnerships with the U.S. Food and Drug Administration (FDA), shared the responses from several participants to the first question about incentives for global health engagement. She noted that a major incentive is to get the business model correct in order to allow the initiative to be sustainable. Significant incentives for governments include the huge need for
assistance and the limited resources available. Another incentive for a company is the knowledge-base advancement that would likely result from its contributions to or participation in global health engagement. In addition, Valdez highlighted that company engagements that help society also need to be good for business. An incentive for government to participate in multi-sectoral engagement is to learn best practices, and an incentive for civil society is to access resources and recognition. She noted a challenge: the time line for completing an initiative does not always align with the time line for demonstrating its impact.
Monahan shared that several participants agreed on the reason for partnerships—organizations cannot achieve their goals in isolation. Additionally, because there are many middle-income countries with large poor populations, the roles of the government and the private sector in granting people access to benefits and services need to be considered. Finally, for the government and for NGOs, partnerships are a way to start conversations about changing how the private sector does business to improve health.
Dolley added that multi-sectoral engagement provides an opportunity both to scale interventions and to better engage with local communities. Another participant noted that their group discussed that multi-sectoral engagement is useful for accelerating new ideas and innovations to drive maximum impact. It also allows multiple organizations to inform the broader public health agenda. Other major incentives are the cost-sharing, knowledge-sharing, and de-risking aspects of involving multiple sectors.
Donald Bundy, professor of epidemiology and development at the London School of Hygiene & Tropical Medicine, explained that his group focused on the determinants of organizational decisions about partnerships. They described three types of organizations: development banks, funding alliances, and those in the private sector. Each type of entity makes its own decisions regarding engagement, and each has a different group that makes decisions about how investments could happen.
For example, governments decide on providing financing to other governments through development banks. In funding alliances, a mix of funders makes the decisions, and that can enable extraordinary flexibility. In the private sector, shareholders make the ultimate decisions about engagement.
James Coughlan with The UPS Foundation delineated the difference between long- and short-term partnerships. He also questioned whether most partners consider the “long-term view” because sometimes, partnership leaders understand how to address a problem but lack the ability to convert their understanding into action. He noted that influences on engagement include politics, ownership of the initiative by all stakeholders, and the willingness of stakeholders to adapt.
In response to the second question regarding deterrents to multi-sectoral engagement, another participant stated that resources (e.g., time and money) and the practical realities of ongoing projects—including their complexities—may deter engagement. Other deterrents may be unfamiliarity with or ignorance about how other organizations work as well as ideological, language, and cultural differences. There also may be a lack of incentives for risk taking among people responsible for partnerships because they are rarely rewarded for their roles in partnerships. Another factor may be a lack of understanding around the legal environments in which partnerships happen or a lack of clarity about whether a partnership, rather than a single organization, needs to undertake the initiative.
Olusoji Adeyi, director of the Health, Nutrition, and Population Global Practice at the World Bank Group, noted that his group described one deterrent to multi-sectoral engagement: partnerships do not always lead to positive results in the short term, and the negative publicity that could result may lead to risk aversion. Adeyi noted that people in the public health field often fail to ask the “compared to what?” question. If an initiative is imperfect, the assumption is that the counterfactual is perfection. In actuality, the counterfactual may already be imperfect from the start.
Valdez added that additional deterrents include an assumption of malicious intent when a mistake is made and a lack of recognition of contribution—especially when the contributor is from industry. She suggested there is a double standard for industry when compared with government; government is often forgiven when it makes a mistake, but industry is not. Kumar substantiated this point by noting that even when multiple partners have seats at the table, they may not always have the same voice or credibility.
Another participant noted that hesitancy to act on a new idea or to establish a new relationship, as well as the complexities involved with multiple parties, can deter multi-sectoral engagement. Additionally, different stakeholders often have different agendas, and finding the intersection between agendas can be challenging. Morris added that engagement in multi-sectoral partnerships is also resource-intensive for public stakeholders, and it requires significant time for and investment in planning, marketing, and communicating.
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