The workshop’s second day focused on political leadership, policies, and governance issues as they relate to public–private partnerships (PPPs) in urban health. The morning started with a presentation by Niels Lund, vice president for health advocacy at Novo Nordisk, and was followed by a discussion that included Lund; Clarion Johnson, private consultant to ExxonMobil; and Ann Aerts, head of the Novartis Foundation. Johnson moderated as well as participated in the discussion. Next, two elected officials made presentations: The first was Ricardo Baptista Leite, member of the Health Committee and the Foreign Affairs Committee in the Portuguese National Parliament, national health spokesperson for the Social Democratic Party, and head of public health at the Universidade Católica Portuguesa’s Institute of Health Sciences. The second was Charlotte Marchandise-Franquet, deputy mayor for health for Rennes, France, president of the French Healthy Cities Network at the World Health Organization (WHO), chair of WHO’s Healthy Cities European Network Political Vision Group, and co-chair of the Global Urban Air Pollution Observatory. Jo Ivey Boufford moderated the workshop’s final discussion after Baptista Leite and Marchandise-Franquet presented.
Niels Lund (Novo Nordisk) explained that one of the more unusual features of some European countries, such as Denmark, is that their laws allow foundations to own for-profit companies; this creates foundations that drive and control a for-profit business but have a philanthropic mission. The result is an entity obligated by law to reinvest the dividends it receives via the corporate shares it owns or to disburse them as grants. Novo Nordisk’s philanthropic arm, for example, awards grants totaling $900 million to $1 billion per year.
Lund said Novo Nordisk’s three-tier approach to working sustainably calls for the company to act responsibly, integrate social and environmental priorities with financial responsibilities in its business strategy, and help address global issues—including those that go beyond self-interest. As a pharmaceutical company, said Lund, Novo Nordisk has to take a
long-term outlook for any of its investments; over the long term, social and environmental concerns also become financial ones. In that respect, the company sees opportunities in addressing global issues such as the United Nations (UN) Sustainable Development Goals (SDGs) and the growing burden of noncommunicable diseases (e.g., diabetes) recognized by the UN.
Lund then turned to the Cities Changing Diabetes initiative and noted that, as Napier explained earlier, diabetes is rising at an alarming rate around the world (see Figure 7-1). Without action, 11.7 percent of the world’s population, or more than 700 million people, will have diabetes by 2045 if the current trajectory holds. Lund said, “That is a lot, but that is actually what it will require to bend the curve, and it says something about the level of ambition we need to have.” He then added that bend-
ing the curve for diabetes can serve as a model for altering the trajectory of other chronic diseases.
Lund noted that an urban focus for interventions makes sense given that two-thirds of people with diabetes live in cities (IDF, 2017) and that cities are where inequities are highest. He added that cities influence how people live, work, and eat, all of which affect obesity and diabetes (Tellnes, 2005). He noted that although there are great opportunities to intervene given the relationship between diabetes, obesity, and city planning, no organization can solve this problem alone—not even the health sector. Reflecting that, Cities Changing Diabetes has been collaborating with climate leadership group C40 Cities to map the health benefits that would accrue through action to mitigate climate change and vice versa. It has also collaborated with the Eat Foundation to develop advice on food and nutrition for cities. As of July 2019, 22 cities and more than 150 civil society and academic institutions are partners in the Cities Changing Diabetes initiative, and more cities are expected to join over the coming years.
Lund noted the importance of all partners realizing some value in any partnership, and that holds true for Cities Changing Diabetes. For people with diabetes, the program will foreground their voices, improve their access to resources, and improve their quality of life. For cities, the partnership offers access to new insights about risk factors for diabetes; a platform for action to reduce morbidity, raise productivity, and cut spending; and a PPP that aims to improve the city environment. For Novo Nordisk, the program provides sustained access to stakeholders, a platform to improve the company’s reputation, and a platform to put diabetes on the political agenda.
Bending the diabetes curve will be an iterative process driven by knowledge acquisition and experience. This process has started with the development of a diabetes projection model that can estimate the effect of a specific intervention on the curve. The program also maps future challenges by identifying social and cultural dynamics that affect diabetes vulnerability and then by developing hypotheses about what is needed to address those dynamics. The program will share solutions it develops through knowledge networks, publications, exchange visits, and summits, and it plans to translate global research insights and best practices into local policy and action. Lund said a key lesson so far has been that Novo Nordisk, as a pharmaceutical company, has to ensure it builds trust among its partners and the cities in which it works.
Based on work completed so far, the program has identified four action areas: places, community, food, and health care. Places shape the way people move and interact, and they affect health on several levels, Lund said. City planning, he explained, can transform cities from relying predominantly on cars to being more bicycle friendly and can benefit
both health and climate. Community can engage people outside of the formal health care system. In particular, faith-based communities can reach broad groups of people, target prevention efforts in a safe environment, and overcome mistrust and loneliness. Lund said food, of course, is vital to health, and being able to access healthy foods—through establishing sustainable food systems—needs to be an essential part of any effort to bend the curve. Access to affordable, quality health care, in terms of both prevention and treatment, is also vital to health. Along with increasing access to care, it is important to train doctors to ensure they understand the benefits of addressing diabetes with their patients. Lund then noted the importance of raising the profile of public health among policy makers at city and national levels. To reach policy makers, the program is assessing the economics of diabetes and obesity prevention, including the economics of designing and piloting social investment programs.
A program review conducted from 2014 to 2016 found that Cities Changing Diabetes has contributed value to its partners. The participating cities reported that the program acts as a catalyst for change by facilitating a process that builds new relationships around shared insights and common goals. The program has built relationships as a foundation for action by convening stakeholders who do not normally collaborate on shared goals. It is also building a new evidence base and developing new research tools that change perspectives and practice. Through such actions, it contributes to generating a more holistic and multidisciplinary approach to tackling diabetes in cities. Finally, the review found that the program is playing an important role in facilitating change by promoting existing agendas and goals or by facilitating or accelerating changes that were not already planned.
In the future, Cities Changing Diabetes will take a long-term approach to bending the diabetes curve and improving population health by 2045. Between today and 2025, the initiative aims to implement health actions and policy changes in cities that will create new social norms, behaviors, and health-promoting environments over subsequent decades. Lund noted that the initiative’s goal over the next 5 years is to start delivering on key objectives: implementing more health actions in more cities; building a stronger evidence base on challenges and solutions and then disseminating that knowledge; establishing a greater focus on health policy at the city, national, and global levels; and engaging in advocacy on city, national, and global agendas to show that action on urban health is necessary, desirable, and achievable.
Johnson began the discussion by noting the importance of Lund’s emphasis on long-term views. He said, “If you are going to introduce any-
thing that has a preventive component, those three words are essential.” Aerts added that long-term engagement is missing from the Better Hearts Better Cities urban hypertension initiative she and her colleagues are driving. The initiative, she said, only received approval to work in three cities because, unlike Cities Changing Diabetes at Novo Nordisk, Better Hearts Better Cities is not run by a corporation; it is run by the Novartis Foundation, which is separate from corporate Novartis. Lund commented on the importance of selecting cities that are able to engage in a partnership and for which the program has sufficient resources to invest. He noted, “Many cities will not have that human resource to drive a collaboration.”
Johnson then asked who could be at the initial table and whether that initial group needs to be involved throughout the project. Aerts replied that the Novartis Foundation initiative chose cities by evaluating disease burden and likelihood of program success, both of which are based on a country’s stability and on a city’s willingness to engage. Better Hearts Better Cities gathered local stakeholders only after the mayor of a city agreed to participate and clarified what the city wanted from the program and which sectors it wanted involved. Typically, the list of stakeholders includes city health authorities, national finance ministers, information technology companies, insurance organizations, patient associations, sport associations, school officials or the education minister, and employee associations. She noted that one difference between Better Hearts Better Cities and Cities Changing Diabetes seemed to be that Better Hearts Better Cities relies mostly on local resources, but the Novartis Foundation provides seed funding for the “risky” or most innovative parts of Cities Changing Diabetes—parts for which governments do not necessarily have the budget. Lund said that the composition of the partnership for Cities Changing Diabetes depends on context. For example, more than 75 organizations belong to the coalition in Houston, but because civil society organizations are less prominent in China, government is the major partner there. He added that including a local research institution is important because such institutions usually know the major local issues and ensure an unbiased analysis of local situations and potential challenges.
Recounting his experience with ExxonMobil’s malaria program, Johnson explained how the company approached him after a series of employee deaths from malaria and wanted him to start a program to cure the disease. Johnson knew this was impossible but found a way to explain that although curing malaria was beyond his capabilities, developing a program to better manage the disease and prevent deaths would be feasible. Eight years later, no deaths from malaria have occurred, and between 4,000 and 5,000 cases of malaria have been prevented. He also noted that testing whether people were compliant with their antimalarials cost $200
when the program started because samples had to be sent to Scotland on dry ice for analysis. Later, working with the French Army, the program developed a simple urine dipstick test that immediately determined whether employees were compliant with their antimalarials—for pennies per sample. Taking antimalarials was not a condition of employment, but it was a condition for being deployed in certain regions.
Responding to a question about program financing, Lund stressed the importance of developing a cost–benefit analysis for obesity and diabetes programs that parallels those developed to curtail smoking and alcohol abuse. His team is doing this in Europe. Lund said
If we work with interventions that address both the social aspect as well as the health aspect [of diabetes prevention and treatment], I am quite confident that we can show a return on investment through reduced cost as well as improved tax collection and productivity gain. We can then either de-risk outside investments or simply have the program funded through long-term commitments by the municipality.
Sir George Alleyne from the Pan American Health Organization noted that getting long-term commitments from politicians is difficult because their reelection cycles occur every few years. He asked how programs can work with civil society to ensure continuity of interest. Lund replied that although working with elected officials is difficult, sustaining programs that are not anchored in local political processes and local decision making is also difficult. That said, Lund noted that the collaborations his program helps form do engage local civil society because those are the organizations that produce change on the ground.
In the 1970s and 1980s, said Ricardo Baptista Leite (Portuguese National Parliament), business schools began looking at new management models, particularly those deployed in the Japanese auto industry, as a guide for reforming the health care sector (which physicians considered to be poorly managed). This transformation led to what Baptista Leite referred to as the industrialization of health care: a process motivated by the belief that health outcomes will improve when the health sector becomes more productive and produces more efficiently. Baptista Leite said, “We all know what happened there. We ended up with a rise of the burden of disease and a rise in costs, which leads to risk and unsustainability, and compromises our universal aim—through the SDGs—of achieving universal health coverage.” Poorer health outcomes, he noted,
affect everyone but mainly affect the most vulnerable populations, and that dynamic creates a vicious cycle of inequalities, inequities, and poverty that, in turn, increases the burden of disease and raises the cost of health care even further.
The main problem, Baptista Leite said, is that hospitals have become factories of health production and are incentivized to produce more in order to be paid more. An alternative to incentivizing higher volume of treatment, he said, is to incentivize good health outcomes and good experiences for patients. He then discussed Portugal, where half of the country’s primary care physicians are paid based on performance, and half are paid a salary regardless of their patients’ outcomes. The system in Portugal, he noted, demonstrated that paying for performance based on an audited set of outcome measures, rather than on volume, improves health outcomes for patients with arterial hypertension and type 2 diabetes by roughly 24–26 percent and 21–28 percent, respectively (Alves et al., 2016).
Baptista Leite noted that increased spending on health care, particularly in low- and middle-income countries, produces better health outcomes. However, this holds true only to the point at which outcomes plateau or even dip slightly, as they do in the United States (see Figure 7-2). A major question prompted by the data is how to generate even better
outcomes in the future without compromising the sustainability of the world’s health systems. Baptista Leite said, “To deal with that, we need to understand what comprises our health status.”
Based on his experience as a physician, Baptista Leite said he probably sees only 10 percent of what affects a particular patient’s health; the remainder includes 30 percent from biological factors and 60 percent from economic, environmental, social, and behavioral influences. He said, “The truth is, we are only normally dealing with the 10 percent, and that is why looking at the social determinants of health is so important.” For this reason, he believed that applying the value principle not only to the health care system but also to the community will improve health without bankrupting national health care systems. Creating such a community-based, value-based system requires partnerships that include local government, education systems, private and public sectors, and nongovernmental organizations and that establish what he called community-based outcome measures. Baptista Leite explained, “Instead of just focusing on controlling diabetes or hypertension, we can actually create incentives toward lowering the incidence and prevalence of hypertension and diabetes.”
Baptista Leite firmly believed that public health will not enter mainstream discussions in either politics or health care if it fails to be integrated into larger financing systems for health care. Otherwise, he said, public health will continue to be seen as a side endeavor and will receive less than 3 percent of national health budgets.
When Baptista Leite was elected deputy mayor of Cascais, Portugal, a city of 200,000 people located 20 kilometers from Lisbon, he began working on a project he called Cascais 2030. This project translates the 169 global indicators included in the 17 UN-approved SDGs to the local level. For example, one indicator for SDG 3 calls for universal health coverage; at the city level, this translates into every citizen having access to a family doctor. Today, city council members submit proposals through a digital portal that requires them to indicate which of the 17 SDGs the proposal will address. The city’s residents gather annually to review what the city has done to meet the SDGs. Baptista Leite noted the most relevant part of this activity: it influences the city’s budget. When data show the city lagging on certain goals, the city can alter its budget to move those areas forward. As an aside, he noted that although Cascais has won many awards for its work on climate change and adaptation, data from the portal suggest the city has actually performed worst on that goal. Baptista Leite said, “It goes to show that if you do not measure, you just believe whatever the awards tell you.”
A second project he discussed was Smart Health Cascais, which aims to monitor key health and social indicators among city residents. The genesis of this project, Baptista Leite explained, was his interest in under-
standing what the city received for the millions of euros it spent on nongovernmental organizations and other contractors that delivered a wide range of services. By geo-referencing all of the indicators the project had developed in the health, education, and social sectors, he and his colleagues could generate data down to the neighborhood level. The resulting analysis showed, for example, that the percentage of residents who lacked a family physician varied significantly across the city (see Figure 7-3). Similarly, data on the number of prescriptions written for antidepressants and antianxiety drugs identified parts of the city that may benefit from more mental health services (see Figure 7-4), and data on obesity and diabetes allowed the city to redesign its bike lanes to traverse the most critical areas.
He noted in closing that the data collected by Smart Health Cascais are available to the public. This transparency helps with accountability and creates an incentive to push people in the right direction. The availability of real-time data also allows city governments to adapt their policies and programs in a timelier manner. He said that achieving universal health care will be impossible without the participation of nongovernmental and community-based organizations and of the private sector. Baptista Leite commented, “If we do not work with civil society, we will leave people behind, and we will not have true universal coverage.”
The WHO European Healthy Cities Network, which has existed for more than 30 years, includes 1,500 cities in 29 national networks, explained Charlotte Marchandise-Franquet (city of Rennes, France). In France, nearly 100 member cities had a budget of more than 200,000 euros in 2018, a 50 percent increase from 2014, and she expected the number of participating cities to reach 200 by the end of 2019. The vision of the WHO Healthy Cities program, she added, is to address inequities in health care and leave no one behind.
In her view, health is a political choice. In theory, Health in All Policies frameworks include all necessary stakeholders at the table to discuss a given problem and develop policies to address it. In reality, though, developing policy involves substantial legwork, data, and education to address complex dynamics among different stakeholders (Lacouture et al., 2015). It also involves appeasing various constituencies and social movements, which can require overlooking particular data or acting without data.
This is where the WHO Healthy Cities Network enters. It empowers city mayors to use their convening abilities to get people to the table; their positions and communication skills, as well as the best research available, to influence public opinion; and their clout to develop win–win strategies and partnerships. Equally important, Marchandise-Franquet said, is the fact that mayors in the network speak with one clear message on health and well-being.
Her city, which includes 450,000 people in western France, conducted a project to integrate health into the renovation of a deprived neighborhood. The first step was to map health inequalities by neighborhood to identify areas that needed attention The project team then used the data to enter particular communities and speak with people who lived there to solicit actionable ideas about how to address specific problems that affect morbidity and mortality in those neighborhoods. Then, they mapped every actor involved in a particular neighborhood’s renovation to determine which actors could enact which solutions. For example, the city wanted to build a new school in the neighborhood. However, because it would be located on a major road, some people worried that students and teachers would be exposed to high levels of air pollution. Working with school officials and architects, the city designed the school to minimize exposure to automobile exhaust.
In closing, Marchandise-Franquet said that creating healthy cities requires a global vision, not a mere sprinkling of a little of this and a little of that onto existing problems. The Healthy Cities movement represents an ecosystem that addresses the complexity of cities and the issues that adversely affect their residents.
Boufford began the discussion by asking panelists how they started conversations about change with their colleagues, people in power, and the public. Baptista Leite said he pushes for policy change by using the acronym EDA—evidence-based, data-driven, and action-oriented. He noted, “Coming from an academic field, evidence should be our bread and butter.” Many change conversations fail because they are not oriented toward action. Being oriented to act means raising awareness among the public first; any program not in line with public concern will never be approved by politicians. What is needed, he said, is for the public at large and for policy makers specifically to understand that health is more than a social policy issue. It is also an economic tool to drive social justice, inclusive wealth, and growth. Accomplishing those goals requires data both to inform policy makers and the public and to adjust projects when needed.
Data, said Baptista Leite, can also generate tools. For example, his university has created an app called Let’s End Hepatitis C. The app, which uses mathematical models to predict outcomes based on various policies and implementation plans, transformed Romania’s plan to eliminate hepatitis C in the country. Baptista Leite said the country is now on track to eliminate this disease by 2029.
Marchandise-Franquet recounted how her city changed alcohol consumption practices by changing its messaging about binge drinking.
Instead of saying alcohol was bad, the new messaging encouraged people to drink water along with their alcoholic beverage of choice. Moreover, the message was delivered not by the city government but by peers who were put on the street at night. The result was a precipitous drop in emergencies on Thursday nights—party nights—and an increase in healthy behaviors.
Boufford then asked the panelists to discuss any successful or unsuccessful experiences they have had as elected officials when they work with the private sector. Baptista Leite replied with one of his findings: Corporations are starting to understand that they need to provide a solution that fits into context rather than a technology or product alone. Corporations have also realized they need to think of government as an equal, essential partner in order to be most successful. Portugal, he noted, was able to negotiate payment for hepatitis C treatments based on patients cured rather than on pills dispensed. In return, the involved companies became active partners in the coalition assembled to attack hepatitis C and helped design a protocol for early diagnosis and treatment.
Marchandise-Franquet spoke about an issue she has seen: Corporations often propose programs that will work in more affluent neighborhoods rather than in those that most need the program, or they develop programs without considering the real needs of people who live in less affluent neighborhoods. Such outcomes tend to occur because representatives from those corporations do not work or live in less affluent neighborhoods. This is where the knowledge and connections of city leaders can become helpful.
Robert Clay from Save the Children remarked that many of the workshop attendees, including himself, are comfortable working at the national or the state level on health-related programs but have little experience working with municipalities on urban health. He asked the panelists for suggestions about how to work more productively with cities and city officials. The major difference between working at national and city levels, Baptista Leite responded, is that “you actually get something done at the local level, and that translates into people’s lives in a much more direct way.” Moreover, he added, when a program does not work, city officials hear about it from residents, and that can motivate officials to find new solutions. He also noted, from his experience, that multinational organizations in particular often fail to gain an understanding of local culture and key opinion leaders before they approach the mayor.
Lund noted that PPPs were very transactional in the past—if a city needed its schools cleaned, it hired a company to clean them. While transactional relationships still occur, today’s PPPs are likely to based on shared, purpose-driven values and goals. Companies, foundations, and civil society organizations join municipalities to solve societal challenges.
Baptista Leite noted this transformation enables the development of more sustainable solutions.
Marchandise-Franquet was then asked whether funds to support city-based programs come from national government or local taxes, whether receiving national money then limits what cities can do, and if partnerships with private companies could help cities advocate for more national money. She replied that her city receives funds from the French government as well as from local taxes for its health-related programs, and this money has allowed the city to innovate and improve its residents’ lives. That, in turn, has made the city more attractive for business and investment—people want to live in a healthy city, she said—which makes for good politics at both local and national levels. In fact, France has doubled the amount of money it provides to its healthy cities because the national government has seen the benefits of these programs.
Baptista Leite said it is in the national government’s interest in Portugal to decentralize and to give local governments the authority to provide services and accountability. The problem is that funding does not always follow. What helps cities in Portugal is that money raised from corporate taxes largely stays in the cities where companies are based and that, as Marchandise-Franquet noted, people—and therefore businesses—want to be in healthy cities. The key in Portugal is to lobby at the national level to ensure that decentralization is done well and comes with appropriate resources and that mechanisms for accountability are created at the local level.
As an aside, Baptista Leite noted that his city dedicates 5 percent of its total budget for citizen-nominated projects on which city residents vote. One project, a skate park developed by the city’s youth and approved by city voters, was built on land in one of the city’s most expensive neighborhoods. Baptista Leite noted that what happened next was extraordinary. He said, “Not only did it become the most fashionable skate park in the country, it is a source of revenue for that whole area, and it has actually generated a whole set of social initiatives and movements around it.”
Responding to a question about the extent to which ideology hinders developing effective programs at the local level, Baptista Leite said ideology impedes local progress less; people are more concerned about how a program affects their own lives and about what it means for their children and their neighborhood than they are about ideology. Baptista Leite noted, “If we were to reinforce the role of local governance, then there would be a potential to move away from the ideological stance and go toward what it impacts in the real world, on real people’s lives.” Aerts agreed that local work with a range of stakeholders and with civil society often rises above ideology.
In her closing remarks, Boufford stated that the workshop’s discussions clearly made the case that cities are key actors in driving the global health agenda and that achieving urban health requires work across government, private, and community-based sectors. She said, “None of this happens unless those partnerships are there and those relationships are there, and this requires patience and trust.” The workshop also highlighted several advantages of working with local governments, including gaining critical insights into communities, acquiring data to inform projects, and creating relationships with key local organizations. Decentralizing national authority and resources to local government varies by country, and understanding the real political power of local officials is important.
Another major point raised over the preceding 1.5 days was that health not only equals health care but also depends on urban planning, housing, transportation, food systems, energy, and other sectors and on government’s ability and willingness to work with civil society and the private sector. Boufford noted that, in general, the private sector is relatively absent from broader discussion on the determinants of health. However, interest is increasing within the business community, and there are opportunities to better engage the private sector, particularly at the city level where results can be seen directly by the public and by customers. Boufford stated that it seems clear that incentives will need to be developed to address the relative lack of market forces supporting sustainable PPPs that create long-term shared value for all partners. Some examples have been explored in this workshop, but more are needed to align the expertise, financial resources, and political forces important for improving urban health and reducing urban health inequities—both of which are critical factors in achieving global health.
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