Clarion Johnson opened the second day of the workshop by explaining that the third session would examine innovative elements of specific models of multi-sectoral engagement in global health (see Box 6-1). Moderator Cara Bradley, chief corporate engagement officer of PATH, noted the session would feature presentations on the speakers’ experiences and would be followed by a discussion with the speakers about where innovation remains scarce. It would conclude with an opportunity for participants to respond to questions about their own perspectives and experiences. The speakers focused on multi-sector collaborations in Rwanda that delivered medical supplies through drone technology; multi-sector involvement in the elimination of neglected tropical diseases; and innovative investment mechanisms used to transform digital health systems. This chapter summarizes the presentations and subsequent discussions.
James Coughlan, loaned executive with The UPS Foundation, described a collaboration involving the implementation of a supply chain solution, which involved four main partners: the government of Rwanda, Gavi, the Vaccine Alliance (Gavi), the United Parcel Service (UPS), and Zipline—an automated logistics company that designs, manufacturers, and operates drones as a service to make lifesaving deliveries.1
The initiative began in 2016 when the government of Rwanda contracted with Zipline to launch the world’s first national-scale drone delivery
1 To learn more about The UPS Foundation’s partnership with the government of Rwanda, Zipline, and Gavi, visit https://pressroom.ups.com/pressroom/ContentDetailsViewer.page?ConceptType=PressReleases&id=1462760058735-442 (accessed August 8, 2019).
network. Rwanda, noted Coughlan, had many unpaved roads and two rainy seasons, which made ground travel difficult. As a result, the government of Rwanda asked Zipline to provide blood delivery because it was a necessary but complex supply chain challenge. A small startup company at the time, Zipline enlisted the help of Gavi and The UPS Foundation. With support from these partners, Zipline established the first blood distribution center, from which it now serves about two-thirds of the country (including 21 hospitals). Coughlan noted that the full support of the Rwandan government was central to this success. Despite its complexities and its need to involve civil aviation, the project was able to move through the regulatory process at a typical pace. Two years later, Coughlan noted, Zipline’s aerial delivery service has become routine; it is available to hospitals 7 days per week, 12 hours per day, and dozens of flights occur every day.
The service has made thousands of deliveries and has flown more than 500,000 kilometers. The process begins when Zipline receives an order from a hospital, and the staff fulfills it by selecting and packaging the needed medical products. The package is then delivered to Zipline’s flight operations team. The flight operations team loads the package into an autonomous drone called a Zip. When the Zip is ready to launch, Coughlan explained, it is accelerated from 0 to 100 km/hour in about one-half of a second. As soon as it leaves the launcher, it is completely autonomous. As the Zip nears arrival, an automatic notification is sent to the hospital to alert it of the delivery. To deliver the package, the Zip descends to about 10 meters above the ground and drops the package, using a paper parachute, into an area roughly the size of two parking spaces. This delivery is simple, safe, and accurate—even in severe wind and rain. Following the delivery, the Zip climbs to cruising altitude and returns to the Zipline distribution center to prepare for the next delivery.
Coughlan outlined that the service fits into the country’s blood supply chain in two essential ways. First, it forms part of routine resupply efforts, which involve ensuring a sufficient, fresh supply of high-volume products is available for regular use in hospitals. For example, adult red blood cells are replenished through Zipline as part of the National Blood Service. When a hospital’s stock drops below a critical level, it orders another supply, and the order is filled on demand by Zipline. With this approach, hospitals can be confident they will receive a shipment when needed; because they do not have to keep as much inventory onsite, they can avoid problems created by stocking and expiration.
Coughlan further explained that the second way the service is used is for emergency, or “just-in-time,” deliveries. Remote health facilities occasionally need products they do not stock for reasons related to cost; scarcity; low, intermittent, or unpredictable demand; or special storage
requirements. Such products include pediatric red blood cells, platelets, plasma, and cryoprecipitate. These products are held in a central location at Zipline’s distribution center in lab-quality blood storage equipment. When there is a need for them, a special emergency order is placed through Zipline. When the products are delivered, they typically go directly to the operating room for transmission to the patient.
Coughlan noted that the instant delivery service has eliminated stock-outs while ensuring patients have access to medical products 100 percent of the time. The delivery service has reduced waste by 98 percent—a statistic that even many U.S. hospitals cannot match. The Rwandan government has also saved money using Zipline’s services. Additionally, during the first month of service, use of platelets and plasma increased by 175 percent, which suggests there may have been a lot of latent clinical demand not being met because of access challenges. Coughlan explained that the partnership’s experience showed that coordinated efforts need to be created to disseminate knowledge on when and how to use products as they become more widely available.
Coughlan emphasized that Zipline’s services are having a significant impact on public health in Rwanda—especially because much of the delivered blood benefits maternal and child health and is used in situations such as complicated deliveries, postpartum hemorrhage, and severe anemia due to malaria. He noted that the Rwandan Ministry of Health recently celebrated three hospitals that had zero maternal deaths in 7 months. Two of these hospitals are served by Zipline, and Zipline was recognized as a direct contributor to the success of one. Coughlan also stated that the doctors who benefitted from Zipline’s services reported feeling more satisfied in their roles and better supported by the health system—despite working in very remote facilities.
Looking toward the future, Coughlan concluded that Zipline’s results have allowed Rwanda and other countries to reimagine the possibilities for standards of care at health centers. In the near future, Zipline will also deliver vaccines and vital medicines, and the government of Rwanda will build a second location, which it has already approved, that will allow delivery to every health center in the country within 30 to 45 minutes. Because of these successes, UPS, Gavi, and Zipline now seek to implement a similar solution in other countries.
Donald Bundy, professor of epidemiology and development at the London School of Hygiene & Tropical Medicine, explained that he would
describe two programs in Africa—and how one followed the other. The first was the African Programme for Onchocerciasis Control (APOC) with which Bundy engaged while he worked at the World Bank Group—an affiliation he held for 15 years. The second program was the Expanded Special Project for the Elimination of Neglected Tropical Diseases (ESPEN)2 with which Bundy engaged when he worked at the Gates Foundation. Both programs are large, based in Africa, and well known among people who work in that region. They involve 48 countries within sub-Saharan Africa and benefit 600 million people. The annual per-capita incomes of participating countries vary widely from $600 to $60,000.
Onchocerciasis is a disease commonly known as “river blindness.” According to Bundy, the first program that attempted to eliminate the disease was established in 19743 and operated in 11 countries with a $1 billion budget. The program focused on larviciding affected regions and was successful in eliminating the risk of disease acquisition among approximately 18 million children. Still, although the program was extremely successful, it was also extremely expensive. While it was operational, Merck developed a drug called Ivermectin that treated river blindness. In 1987, Merck’s CEO announced that the company would provide as much of the drug as necessary for as long as necessary to control the disease as a public health problem. Forty years later, the company is still delivering on that promise, but its goal has shifted to elimination.4 Merck’s commitment led to a program shift from larviciding to mass drug distribution. This new program was APOC, and it was led by WHO with funding from the World Bank and 45 other donors. Bundy explained that APOC involved 20 countries and 15 non-state partners, all of which pushed to eliminate the disease through a public health program. APOC’s success attracted interest in neglected tropical diseases from other major pharmaceutical companies, including Johnson & Johnson and GlaxoSmithKline. By 2012, 14 large pharmaceutical companies agreed to the London Declaration,5 pledging that they would collectively provide 1.5 billion doses of medicine through 2020 to address the worst neglected tropical diseases. This donation was worth about $17.5 billion.
APOC focused on onchocerciasis, and the program ended in 2015. By that time, Bundy explained, five principal neglected tropical diseases
2 To learn more about ESPEN, visit https://www.afro.who.int/health-topics/expanded-special-project-elimination-neglected-tropical-disease (accessed August 8, 2019).
3 To learn more about the Onchocerciasis Control Programme, visit https://www.who.int/blindness/partnerships/onchocerciasis_OCP/en (accessed August 8, 2019).
5 To learn more about the London Declaration, visit https://unitingtocombatntds.org/london-declaration-neglected-tropical-diseases (accessed August 8, 2019).
in Africa plagued 44 countries. The 44 ministers of health, one from each country, came together and requested a program that would deliver on the promise of the 2012 London Declaration. As a result, ESPEN was launched in 2016 as a mass treatment program led by WHO Africa. The program was overseen by 44 governments, and it had 14 donors and additional non-state partners. Through this transition, ESPEN emerged as a new structure and assumed many of the APOC functions but operated with a much broader scope. It was also improved by what had been learned from APOC.
Bundy outlined four central players in ESPEN’s development: the private sector, multilateral development partners, bilateral and non-state development partners, and country governments. Because ESPEN delivered about $4.5 billion in products per year to these 44 countries, the bilateral and non-state development partners were incentivized to compete for branding power as a means to garner more resources for their own organizations. Within the private sector, significant supply chain challenges resulted from the involvement of 14 pharmaceutical companies: each had different shipping methods and different types and doses of medications. Additionally, ministries within a country’s government (e.g., health, revenue, and customs) often did not communicate, which sometimes led to situations where donated drugs were held in ports because of duties that needed to be paid. The pharmaceutical companies addressed this problem by delivering drugs directly to national pharmacies and managing customs issues along the way.
Medication handling presented yet another challenge. Some of the lesser-known drugs treated only a specific, often obscure, disease, and well-known antibiotics treated some of the other diseases, such as trachoma—but both types of medication needed to be handled differently. Bundy also noted that Ivermectin was donated at a later date to eliminate lymphatic filariasis in Africa. Although donations were intended strictly for two specific diseases, countries often requested donations for other purposes (e.g., treating intestinal worms or scabies).
Several development partners supported ESPEN, including major bilaterals from the United Kingdom and the United States as well as major foundations. WHO and the World Bank were the primary multilateral development partners engaged in ESPEN. According to Bundy, WHO served as an arbiter of demand for the system and created a network- and region-wide data management system to address the logistics of medicine distribution. WHO also coordinated a roundtable of CEOs to determine directions for ESPEN. Because WHO and the World Bank answer to member governments, the ministers of health in participating countries also played essential roles in determining directions for the program. WHO
provided one technical hub for all 44 countries, which meant that replicating technical expertise in each country was unnecessary.
Bundy then described a final challenge: because receiving countries did not pay for the donated medications, supply was not always closely monitored. ESPEN played an important role in highlighting and responding to this situation. For example, ESPEN recovered 132 million tablets of medication that were sitting on pharmacy shelves in 7 countries. He noted that perceiving donated medicines as entirely cost free could result in perverse incentives—for example, it was simpler for countries to continue sending medications to hospitals than to track what was being used and to ensure extra products were returned. Bundy concluded by noting that both APOC and ESPEN were remarkably large and successful programs that benefitted hundreds of millions of people, and their biggest challenges were related to coordination among development partners and to low implementation capacities in the poorest countries.
Digital Square is an innovative investment mechanism that seeks to transform digital health systems, explained Amanda BenDor, the technical program manager with PATH. The project is housed at PATH and has a consortium of more than 40 partners, including multiple donors. Digital Square focuses on strengthening digital health governance and advocacy at the global, regional, and country levels through co-investment, support to global goods, and digital market readiness.6
BenDor explained that the digital health ecosystem has been facing “pilotitis,” which is the proliferation of small, unsustainable pilots and tools that have not been coordinated or scaled. As a result, ministers of health in countries such as Uganda have asked for implementers to more strategically coordinate their initiatives and investments and to implement systems that are tested, scalable, and already supported.
Digital Square supports adaptable, interoperable digital health tools and technologies as well as global goods, which can be used across different countries and contexts. Some examples include iHRIS, a health workforce information system that has been deployed in more than 20 countries, and DHIS2, a national health management information system that has been deployed in more than 60 countries. These tools, BenDor explained, are open-source, designed for standards-based interoperability, and have been scaled already in LMICs. Digital Square supports the
implementation of these and other digital health global good tools and focuses on core software support and community support.
Digital Square supports these digital health global goods through an innovative, transformative application process that fosters collaboration to address country needs. BenDor talked about the first step in this process: a program issues a call for applications and asks respondents for a brief concept note, no longer than three pages, outlining their idea. The notes are then posted publicly on Digital Square’s Open Application Platform. BenDor noted this posting method is innovative because people typically do not openly share ideas they want to pitch to a donor. This approach requires applicants to post their ideas in a public space, and other people have the opportunity to comment and provide feedback on their proposals. Comments may identify, for example, that a project has already been executed or may point to opportunities for collaboration among multiple groups with similar ideas.
The program provides about 1 month for the concept note phase. After review by program leadership, selected applicants are invited to submit a full application of as many as 15 pages. These applications are also posted on an open platform, but their budgets are kept private. Digital Square uses a Peer Review Committee (PRC), comprising a diverse set of digital health leaders, to review the concept notes and applications and to make recommendations about whether applications could be funded as they are, with edits, or not at all. The PRC’s recommendations are nonbinding and are provided to the governing board of Digital Square, which makes ultimate funding decisions.
BenDor emphasized that the open application platform is particularly innovative and allows for a transparent virtual co-creation process. Anyone can review and provide feedback on the concept notes and applications. Digital Square asks applicants to develop use cases that are posted publicly and to include any open-source code.
Digital Square also uses a Global Good Maturity model, which it developed. The maturity model specifies common metrics for understanding a digital health tool’s level of advancement and assesses software maturity, global utility, and community support. The program asks all applicants to complete a self-assessment as part of the application process.
BenDor explained that Digital Square hired Boston Consulting Group in 2018 to help develop a prioritization framework, which the PRC and governing board would then use to assess and score applications on four dimensions: impact, cost, technology, and probability of success. The framework would provide structure during application review. In Digital Square’s last notice cycle using the open application platform, it received 29 applications totaling more than $10 million in funding requests for sup-
port to digital health global goods. Following the full review process, the governing board approved funding for 20 of the 29 applications, totaling nearly $8 million in funding. However, because Digital Square had only a little more than $1 million in funding available, they presented their funding gap as well as their recommendations for where investments need to go. BenDor noted that Digital Square’s open application platform also encourages transparency by displaying to all other funders and collaborators the proposals that were funded, those that were approved but not funded, and those that were not approved.
BenDor highlighted some aspects of the process that work well and some challenges that Digital Square has faced. First, the acceptance of transparency through the open application platform has been transformative. While potential applicants were initially reluctant to post their ideas in an online forum for competitors to see, they have begun to embrace the opportunity to receive feedback and to read about other applications. Through the open application site, there have been high levels of engagement, including the generation of new ideas, additional commentary, and increased coordination and co-investment with multiple donors. Investments are being made in a growing number of digital tools.
Regarding challenges, BenDor noted that the greatest one is the funding gap. Digital Square continues to advocate for a variety of investors to raise funds for these digital health global goods. Digital Square is also adapting best practices internally in order to manage technical, communications, contractual, and project management support as efficiently as possible.
BenDor concluded by highlighting next steps for continuing the innovation. Digital Square is improving its platform and process and is looking to partner with implementers to augment support of existing investments. It is also exploring opportunities for in-kind investments, including discussing partnership opportunities with other stakeholders in the digital space to provide resources for digital health global goods. One example of co-investment in the past year was support for a civil registration and statistics platform, OpenCRVS, which was approved through the Digital Square notice process. Although the proposal had a health component, OpenCRVS largely requested support for core investment in a civil registration platform. Digital Square was able to partner with the Digital Impact Alliance (DIAL) to co-fund the proposal; DIAL provided $150,000 for the platform, and Digital Square provided about $70,000 for the health information systems piece.
BenDor closed with a call to action. She asked participants to follow along on the application site, join the PRC, and/or provide co-investment for some of the applications.
After the four presentations, Bradley opened the audience discussion portion of the session by noting that innovative partnerships involve inherent risk, and they need to be able to endure barriers and hurdles. Bradley asked the presenters what they consider to be the prerequisite conditions for innovative partnerships to thrive when they face challenges.
Coughlan responded that all parties need to benefit—although not necessarily equally—in any partnership. For example, potential takeaways could include developing a new solution, identifying a new revenue stream, or implementing an acquisition. He noted that, in the corporate world, leadership from a company such as UPS would regularly meet with executives from large global health companies to exchange information about vision and challenges and to identify potential ways in which the companies could work together. Coughlan suggested this type of open and frank dialogue needs to occur in the PPP space, as well.
Bundy noted that he agreed with Sir George Alleyne’s comment from an earlier session about the three important aspects of a successful partnership: mutuality of interest, specificity of purpose, and a shared understanding of the resources to be brought to the table. Bundy noted that these characteristics need to apply to each of the sectors engaged.
BenDor stated that trust, transparency, and communication are particularly important—trust means having trust in another party; transparency involves being open and honest about what each partner contributes and hopes to gain through the process; and communication means ongoing communication with the right people throughout the development and execution of a partnership.
Gaudenz Silberschmidt from WHO responded to Bradley’s question about the prerequisites for innovative partnerships by adding another important condition: each partner needs to act in a role at which it excels. For example, UPS is a logistics company and would therefore be the partner best suited to managing logistics within a partnership. Next, Silberschmidt asked the panelists if they expected their initiatives to go mainstream—independent from donors. He noted that developing a solution often begins with piloting a project that is then scaled, but scaling is donor-driven. Silberschmidt stated that a market solution, funded by either government or market resources, needs to be the ultimate goal. He asked the presenters for their thoughts on how to move from a scaled, donor-funded initiative to a mainstream one. Byrkit next asked Coughlan and other presenters about the sustainability of their approaches and noted that she sees increased potential for scale and sustainability within public–private collaboration.
Brink agreed with BenDor that a lack of information systems in health is one of the biggest weaknesses of the health system. He asked whether Digital Square has successfully matched people who have digital health solutions to places that need them in developing countries. He noted that he has experienced resistance from governments that were unwilling to implement solutions if they were not developed locally.
In response to the questions about sustainability and taking solutions mainstream, Coughlan explained that drones only solve one small aspect of supply chain challenges. While the program has run, The UPS Foundation has also implemented other initiatives such as a training program for mid-level management to help them build capacity, understand supply chains, and develop a solution in Uganda for the final mile—the most complicated part of the supply chain. Coughlan noted the goal was to have each program operate independently and then to pull them together. He added that a strategy with all three components could more easily be developed and deployed across many countries. In addition, collaboration among and commitment from all partners are essential to sustainability. Coughlan noted that, in Rwanda, private-sector partners accept that the government determines when the next site will open and what the next product will be.
Bundy noted that USAID focuses on how to support countries in gaining self-reliance. Making the solutions for neglected tropical diseases sustainable involves extending solutions to affected populations. Additionally, regional roles, such as a sustained regional center and health monitoring systems, are important. Bundy reiterated a point made in a prior session by Olusoji Adeyi from the World Bank: the benchmarks of success matter.
BenDor responded to Byrkit’s question about sustainability and digital health by emphasizing the importance of investing in developing the local capacity in LMICs to develop, use, and implement digital health systems so that technologists and developers from higher-income countries do not have to enter the regions and complete those tasks. BenDor also responded to Brink’s question about matching the needs of a population through innovation by explaining that, overall, PATH supports the choice of a country government to implement whatever system it chooses. However, PATH may advise the government on systems that are standards-based and those that are interoperable with some of the larger systems that are widely used. BenDor also noted supply chain challenges related to complex logistic-management information systems and stated her organization recommends that developers adhere to standards in order to produce the correct data outputs. She added that it is working to transform health systems from paper to digital and to ensure that correct
data are being captured. People may also need to be trained on how to analyze data and use them to make informed decisions.
Next, Jessica Herzstein, a preventive medicine specialist, asked panelists to comment on the potential of their work for broader application. She noted she could envision the Zipline technology being used in rural areas within the United States. Coughlan responded that his parent company, UPS, has an engineering and information technology department that examines ways different technology can serve some of their commercial needs, including how to best serve islands and rural settings. Colatrella added that Merck has been working with AT&T, Direct Relief International, Volans-I, and other partners to explore the use of drone delivery in disaster situations. She noted that Federal Aviation Administration regulations in the United States complicate such delivery options.
Neeraj Mistry with Georgetown University asked Coughlan if he had any data on the cost and cost-effectiveness of the Zipline initiative and noted that technology can often be expensive. He also asked if the initiative had considered how the technology could be used to distribute additional products such as antiretrovirals and antimalarials to scale up the distributions.
Coughlan responded that the desire to avoid stock-outs in the medical field leads to a situation where products sit on shelves. In a supply chain, however, such a situation is inefficient. UPS is working with global health partners, such as USAID and UNICEF, on projects in Rwanda and in Uganda to identify opportunities to disseminate not only vaccines but also commodities and essential medicines to maximize scale and efficiency.
Benjamin Makai asked BenDor how Digital Square manages intellectual property issues. He noted that he has encountered concerns about trust and has experienced the poaching of openly shared ideas in his work with a telecommunications company. BenDor agreed that fostering trust and communication is important but so are embracing full collaboration, launching innovative partnerships, and harnessing transparency.
After the presentations and main discussion, participants broke into small groups for approximately 10 minutes to cover questions for the small group discussions, which focused on innovative models for multi-sectoral engagement in global health (see Box 6-2). Representatives from each of the breakout groups were invited to share their perspectives.
Benjamin Makai spoke first and noted that several participants described a lack of information at the community level—particularly in
African contexts. He also suggested that implementation challenges exist, which emphasizes the need to leverage data, data scientists, and industry partnerships. Makai described the importance of flexibility regarding time lines and urgency; different funders and partners may have different priorities and pipelines. Colatrella added that multiple private-sector partners already work together toward the same objectives in the health care sector but also leverage each party’s unique strengths. However, this does not happen to the same degree in the tech sector, where intellectual property and competition represent challenges that need to be overcome.
Gael O’Sullivan with Georgetown University explained that her group discussed the meaning of the word “multi-sectoral” and noted that the term had typically been used in the workshop to mean the private sector, government, nonprofits, and civil society. However, she suggested that innovation could also include more direct engagement with the education, environment, agriculture, youth employment, and workforce development arenas that focus on solving health problems. She identified a need to consider the capabilities of smaller actors to address some of the problems because the focus is most often on the roles of larger organizations. O’Sullivan added that metrics and reporting requirements for industry partners may differ from those of civil society and other actors and that more alignment is needed.
Silberschmidt’s group discussed how partnerships often focus on system implementation but lack focus on system innovation. Silberschmidt’s group also discussed issues related to measurements of success, such as determining when a third-party evaluation is needed, who requires evaluations, and who pays for them. He noted that problematic situations may arise when a company in the private sector needs to change its behavior but is also the entity mandating and paying for the evaluation and monitoring.
Valdez said several participants suggested that coordination of innovation, rather than innovation itself, is lacking. Another group member pointed out that innovation is not only driven by technology but also may include design or processes. Valdez noted that the private sector is better than the public sector at bringing together actors from multiple sectors because the government often uses sequential messaging to distribute and collect information about a topic of concern among different stakeholders. In contrast, the private sector tends to bring together all stakeholders to discuss issues collectively, and that approach helps to expedite and create a greater number of solutions to problems. Highlighting Bundy’s example of CEOs from 14 pharmaceutical companies who banded together to address river blindness and other neglected tropical diseases, Valdez concluded that projects or processes will be better when more actors—or even competitors—are around the table.
Mistry spoke on behalf of the final group, which focused on the second question. He suggested that an external entity is needed to scale up and institutionalize a partnership approach. Referencing an earlier workshop suggestion, he described the need for an enabling body, similar to an Institutional Review Board, for partnerships. He believed such a body could be institutionalized at the country level and would be capable of identifying partnership opportunities; providing partnership governance and oversight; reviewing conflicts of interest; and bringing people together across sectors.