Faltering steps towards partnerships

Public-private partnerships for health have been a defining feature of Gro Brundtland's term as director general of WHO. How is WHO performing in its role as a partner?

WHO must “reach out to others,” said Gro Brundtland in her first speech after her election as director general of the organisation.¹ This statement heralded a new era of partnerships between WHO and other health agencies, the private sector, and civil society (box B1).² In this article, I examine how WHO is performing in these alliances, with a particular focus on Roll Back Malaria.

Summary points

• Gro Brundtland's election as director general heralded a new era of partnerships between WHO and other health agencies, the private sector, and civil society

• WHO has found it hard to let go of its traditional role as being “in charge” of global health activities

• The Roll Back Malaria partnership has been plagued by a lack of clear governance and ineffectiveness at country level

• WHO could play an important role in helping countries coordinate new global health initiatives with health systems strengthening

• The organisation needs to articulate a clear policy on working in partnerships, including proper safeguards in its interactions with the private sector

Box 1.

Public-private partnerships involving WHO²

European Partnership Project on Tobacco Dependence

Global Alliance for TB Drug Development

Global Alliance to Eliminate Lymphatic Filariasis

Global Alliance to Eliminate Leprosy

Global Alliance for Vaccines and Immunization

Global Elimination of Blinding Trachoma

Global Fire Fighting Partnership

Global Partnerships for Healthy Aging

Global Polio Eradication Initiative

Global School Health Initiative

Multilateral Initiative on Malaria

Medicines for Malaria Venture

Partnership for Parasite Control

Roll Back Malaria

Stop TB

UNAIDS/Industry Drug Access Initiative

Defining partnerships

Malaria causes about 3000 deaths a day, over 90% of which are in sub-Saharan Africa.³ It is both a disease of poverty and a cause of poverty (fig 1), slowing economic growth by 1.3% per year in endemic areas.³ Roll Back Malaria (RBM) was launched in 1998 as Brundtland's “pathfinder” project,⁴ bringing together the biggest players in health with the aim of halving the malaria death rate by 2010.

Figure 1.

WHO

Global burden of malaria

It has had two major successes. Firstly, it brought together more than 90 multilateral, bilateral, non-governmental, and private organisations. Secondly, it has raised the profile of malaria, particularly through its April 2000 summit in Nigeria.⁵

David Alnwick, Roll Back Malaria's project manager, said that “when RBM was formed, a very deliberate, very considered position was taken to try to avoid a burdensome, cumbersome, formal governance structure.” But Roll Back Malaria recently commissioned Richard Feachem, executive director of the Global Fund, to lead a team in evaluating the alliance, and the team found that the project's loose governance structure made the very concept of partnership unclear. The roles of each partner were undefined, and this “looseness and uncertainty is confusing to the partners themselves; it allows the partners to avoid responsibility and to put blame on others; and it is also confusing to clients at the country level.”⁶

One damaging aspect of this looseness is that it encouraged WHO to “go it alone” and make decisions without adequate consultation with partners. Rather than being a true alliance, Roll Back Malaria was “a WHO programme with friends.”⁶ A recurring theme in my interviews with WHO's partners was their fear that WHO was using its new alliances to get back in the driver's seat in international health policy making. “WHO speaks a language of partnership,” said one senior member of a global health agency, “but the reality is of insecurity and control-freakery.”

Brundtland rejected this accusation. WHO cannot be criticised in this way, she said, “because we are not just anyone, we are not just any non-governmental organisation, we have a responsibility to all the governments of the world, and not every partner has that.” Alnwick believes that Roll Back Malaria “was WHO plus friends because a lot of the energy and leadership came out of the WHO.” The evaluation concedes that it is easy for WHO to become the whipping boy partly because of this leadership role. “In practice,” it says, “partners yield most of the responsibility for RBM to WHO, and then blame WHO for what goes wrong.”

A new role for WHO

As global health cooperation fragments into many different partnerships, WHO is being asked to play a new kind of role—to show strong leadership but also give greater voice to its partners. The role could be described as leading from the middle, rather than the front.

It is not just within Roll Back Malaria that WHO must give more room to its partners, but also in the joint UN programme on HIV and AIDS (UNAIDS), an alliance of UN agencies and the World Bank aimed at alleviating the global impact of the epidemic (table).

From 1986, WHO took the lead on HIV control activities through its Global Programme on AIDS, funded largely by voluntary contributions from donors.⁷ But in the mid-90s donors cut their funding and used it to form UNAIDS. This was partly a protest against the leadership of the former director general, Hiroshi Nakajima. Donors also hoped that UNAIDS would take a more multisectoral approach than WHO. The vote of no confidence from donors had a profound effect on WHO. Instead of asking itself what it could still contribute on HIV and AIDS, it battled with its partners to regain its primacy in this area. Peter Piot, executive director of UNAIDS, says that the spilt was “like a really bad divorce. There was a fantasy of bringing UNAIDS back into WHO.”

But WHO, he said, now needs to redefine itself given that the architecture of global health has changed. “An incredible amount of energy was spent fighting each other, particularly WHO, Unicef, the World Bank, and UNDP [the United Nations Development Programme]. [The fighting] was on territory and policies, with WHO claiming it was the controller, that they were in charge. The world is changed in the meantime. That's why I'm saying that WHO still has to look for its place in the world.”

Brundtland has reinvigorated WHO's AIDS programme, which is providing technical expertise to UNAIDS and giving guidance to countries on drug treatment of HIV, including prices.⁸ Piot believes that WHO should concentrate on this kind of guidance, and not try to become the leader of the world's global efforts to control HIV. Joep Lange, president of the International AIDS Society, agreed: “We need a global plan with all partners.”

Governance

The external evaluation is blunt about Roll Back Malaria's governance: “RBM has no governance structure.” Alnwick rejected this assessment, arguing that the partnership, whose secretariat is housed by WHO, is accountable to WHO's member states via the World Health Assembly. While this is true, it means that there is no mechanism for all partners to share decision making. Kent Buse, assistant professor of international health at Yale University, said that “WHO has not been willing or able to establish such shared governing arrangements and this begs the question of how WHO defines the ‘public-private’ in these partnerships.”

Buse believes that the best model for achieving shared governance is the one used by legally independent partnerships, such as the Medicines for Malaria Venture and the Global Alliance for TB Drug Development. “These have established boards,” he said, “with explicit fiduciary and oversight responsibilities, and to whom the senior management is responsible, with representation from both public and private sectors.”

Partnerships housed by UN agencies could adopt this kind of model. One partnership that has done so is the Global Alliance for Vaccines and Immunization (GAVI).⁹ It is housed within Unicef, but—in contrast to most partnerships housed within WHO—it has a governing board that represents public and private partners. The board has 11 members, three of whom are representatives from developing countries.

There is a clear need to establish best practice in the governance of public-private partnerships for health. Buse and Waxman have proposed a framework that WHO could use in ensuring good governance (box B2).¹⁰

Box 2.

A framework for good governance of partnerships involving WHO¹⁰

Partnerships should:

• Establish clear goals, roles, responsibilities, and decision making structures
• Consider the means of monitoring and enforcing decisions
• Establish systems of communicating information about decision making structures, funding, resource allocation, and results to all concerned
• Document and publicise details of the process and outcomes of the partnership

Governing bodies should:

• Be widely representative
• Give WHO adequate decision making power, reflecting its position as the premier health agency with universal representation
• Have mechanisms ensuring the participation of constituencies that might otherwise lack the material resources needed to participate

Country support

Willem van de Put is director of HealthNet International, a non-governmental organisation that collaborates with WHO in post-conflict zones, where malaria is often rife. He had high expectations of Roll Back Malaria. “But we're disappointed,” he said, “that something so widely advertised, with so much attention, turns out to be no more than the sum of its parts. If we want to do malaria work, we're still trying to work out how we can work with RBM. We know there is an initiative, but what is it? Money? Expertise? It's all in the air.”

At country level, Roll Back Malaria's presence and activities are often criticised as ephemeral. There has been “no push,” said Fred Binka, who used to work with Roll Back Malaria and who is now at the University of Ghana, “to try to get something done on the ground.” WHO's regional offices are important to Roll Back Malaria's success. “Some regions have done well,” said Binka, “but the African region was understaffed and couldn't deliver.” The region gets blamed for underperforming, he said, yet “headquarters gave no support, no capacity strengthening” (box B3).

Box 3.

Malaria in the African region

Roll Back Malaria faces its greatest challenge in sub-Saharan Africa. Malaria is Africa's leading cause of mortality in children under 5. It accounts for 40% of public health expenditure, and up to half of all inpatient admissions and outpatient visits in areas where transmission of malaria is high.³ The cheapest antimalarial drug, chloroquine, is rapidly losing its effectiveness in almost all countries where malaria is endemic.

WHO's regional office for Africa (AFRO) has an important role to play in Roll Back Malaria's malaria control activities. It is currently located in Harare, but at least part of the office is moving to Brazzaville, a move that is likely to make it more isolated. Unfortunately, a “politicized and inflexible bureaucracy impedes the ability of AFRO staff to provide effective support to their client countries.”⁶ Staff are stretched to capacity and lack the resources needed to provide intensive support to countries.

Fred Binka is an African malaria expert who has experienced firsthand the problems facing Roll Back Malaria. “At country level in Ghana,” he said, “there has been more frustration than joy. To get this off the ground, there is a need to get countries the necessary human and financial resources. Most countries are helpless—they don't have the tools.”

Malaria is endemic in 42 African countries, said Binka, yet the partnership created only three malaria posts in Harare, which was “woefully inadequate.” It attempted, he said, to develop country teams to support country level activities, but these teams were weak. In many cases, the WHO country representatives were not technically equipped to deal with malaria control issues. “I will say that, at least in the African region, on balance not much has changed. This isn't a new era, a new dawn for WHO.”

Roll Back Malaria partners have agreed that an important immediate step will be to create “inter-agency, inter-country teams.” These teams will involve Unicef, WHO, and regional malaria advisers from donor-supported initiatives such as the Malaria Consortium and Malaria Action Coalition. These agencies will work together to provide coordinated and continuous support to a small group of countries.

The external evaluation found that Roll Back Malaria's global and regional processes have made little impact on national malaria control programmes. The evaluation also found scant evidence that Brundtland's vision of “one WHO” was becoming a reality. Instead, an “uneasy relationship” between WHO's headquarters and its regional offices was hindering the partnership's effectiveness, particularly in Africa. The evaluation team's suggestion was to focus on a few “spotlight countries” that can show measurable success in malaria control within a few years. In recognition of these concerns, Roll Back Malaria foresees the establishment of three subregional offices in Africa plus a strengthening of its focus at country level. If Roll Back Malaria cannot show results soon, its credibility and future will surely be in doubt.

Short term, high profile goals

One of the obstacles facing the new public-private initiatives is that they are being rolled out in countries with weak health systems. For example, an assessment of GAVI's impact on four African countries raised concerns about whether these countries were sufficiently prepared and resourced to roll out the new vaccine initiative.⁹ There is a tension between a donor-driven global partnership aiming for short term, high profile goals and the need for countries to broadly develop their health systems. Partnerships tend to “pick the low hanging fruit”—they concentrate their efforts on getting quick results rather than building up the wider systems needed to address the broader burden of disease.

Another related problem is that partnerships rarely synchronise their activities with emerging processes within countries aimed at developing their health systems. The evaluation of Roll Back Malaria found that the initiative was not linked up to sector-wide approaches, where donors contribute to a single pot of funds that support a country's whole health sector rather than individual disease programmes.¹¹ Nor was it linked to the World Bank's poverty reduction strategies¹² or its programme of debt relief for heavily indebted poor countries.¹³

Are partnerships undermining WHO's core activities?

Poor countries do not have the resources to coordinate the bewildering array of new public-private partnerships with programmes aimed at health systems support. WHO arguably has the mandate, though not the budget, to help governments with this coordination. Public-private partnerships could inadvertently undermine WHO's core activities, including country support, by diverting resources away from such activities. If the donor community concentrates its spending on these partnerships, which are mostly single disease programmes, and if WHO also diverts its resources towards them, there will be fewer resources at WHO's disposal for its core activities.

Brundtland denies that this will happen. The increase in voluntary donations to WHO during her term, she said, shows that more funds are flowing to the organisation. But donors are still earmarking these for specific vertical programmes, and so a question remains over how WHO's less glamorous but increasingly important country support work will be funded.

Private partners

Some academics worry about the private sector's involvement in partnerships for health.¹⁴,¹⁵ Could the private sector, they wonder, distort the public health goals of the UN agencies? Carol Bellamy, chair of the board of the Global Alliance for Vaccines and Immunization and executive director of Unicef, has warned that “it is dangerous to assume that the goals of the private sector are somehow synonymous with those of the United Nations, because they most emphatically are not.”¹⁶

But the private sector has a vital role to play in improving global health, and WHO must engage with it. The difficult question is how close this engagement should be. Roll Back Malaria's recent partnership with the company Novartis, for example, has caused alarm among some malaria experts (box B4).

Box 4.

WHO's partnership with Novartis: cause for concern?

Roll Back Malaria is seeking alternatives to chloroquine for treating malaria in resistant areas. There is particular interest in combinations of drugs that include derivatives of artemisinin. Paul Garner, professor at the Liverpool School of Tropical Medicine, said that “there are good strategic and scientific reasons to use artemisinin drugs in combination with other drugs, as these slow the development of resistance, but there should be good evidence that the particular combinations are at least as effective as other regimens to cure patients.”

In areas where multidrug resistant malaria is emerging, Roll Back Malaria is advising governments to use artemisinin based combination drugs to treat the disease. The only combination drug ready for use is one that is produced solely by Novartis: artemether-lumefantrine (Coartem). It is expensive, and the company has agreed to provide it for use in malaria endemic countries at what it states is the cost of production. Recently a systematic review of the drug found that it was more effective than chloroquine in chloroquine resistant areas, but less effective than some cheaper alternatives.¹⁹ The authors, of whom Garner is one, found insufficient research evidence to compare it adequately with sulfadoxine-pyrimethamine, one of the main drugs in use in Africa.

Given this lack of proved effectiveness, said Garner, why did Roll Back Malaria not insist that the company conduct proper studies comparing its effectiveness against existing antimalarial regimens? Why is the project particularly promoting Novartis' drug as first line treatment for malaria?

When I interviewed David Alnwick, Roll Back Malaria's project manager, boxes of Coartem were on display in his office. “Should I take the boxes of Coartem down,” he asked, “when the press or TV come? No. Why have I got them up there? Because at the moment this is the best single drug around for treating malaria in countries that have got multidrug resistant malaria. Should I be ashamed of the fact that we've worked with Novartis to improve access to developing countries to the drug? Absolutely not. Why not? Because I think we're entirely open, and have been open, in saying that it is a real pity that Novartis is the only group in town making this drug. While they may own the intellectual property on this particular drug, there are four or five similar drugs out there waiting to be developed.”

Hans Hogerzeil, a member of WHO's essential drugs and medicines policy group, said that “there are different ways for WHO to be in contact with commercial companies” and each requires different rules of engagement. WHO's tropical diseases programme, for example, must work closely with industry to develop new drugs. But WHO's essential drugs department should be “totally fire-walled off, because we, through the expert committee, have to finally decide, independently, is this a good drug or not—is it recommendable, is it safe?”

WHO knows it must tread carefully in its interactions with industry and has formulated guidelines for its staff to govern these.¹⁷ It is unclear, however, how closely the guidelines are being followed across the organisation, and they are vague about important issues such as screening potential corporate partners. Until WHO addresses this vagueness, it will continue to stumble into situations in which it seems to be too close to the private sector. Many WHO staff, for example, were amazed that the official lobbyist of the pharmaceutical industry was asked to write a policy paper on generic drugs for WHO's Commission on Macroeconomics and Health.¹⁸ One senior WHO insider said that the episode showed a “fatal error of judgment” on Brundtland's part.

Taking stock

Daniel Tarantola, one of Brundtland's senior policy advisers, said: “We are now in a phase of taking stock—looking at the good and the bad in these alliances, and recreating and refocusing what we do.” He believes that the lessons from partnerships to date point to a few important questions. What sort of composition should they have? What should their relationships to governments be? When should they and should they not involve the UN system?

This kind of appraisal is desperately needed. WHO has not articulated a clear and consistent policy on working in partnerships, and yet it is increasingly entering into them. Not all staff embrace the new direction that WHO is taking, and yet this diversity of opinion is rarely heard. The organisation needs a sound policy that has come from a process of open discussion and debate.

Conclusion

WHO has yet to find its feet as a partner in a global health landscape that is becoming dominated by partnerships. An analysis of Roll Back Malaria shows that WHO could fulfil an important new role, helping to define the governance of partnerships and the responsibilities of each partner. It is well placed to support countries in the local implementation of new global health initiatives, and in coordinating these initiatives with strengthening of health systems, but it is unclear how it will get the funds to do so. Proper safeguards in its interactions with the private sector will go a long way towards inspiring confidence that these initiatives are truly serving public health.

Table.

Number of adults and children (age <15 years) living with HIV infection or AIDS, end of 2001²⁰

Category	Total	Adults	Women	Children
People newly infected with HIV in 2001	5 000 000	4 200 000	1 200 000	800 000
Living with HIV or AIDS	40 000 000	37 100 000	18 500 000	3 000 000
Died of AIDS in 2001	3 000 000	2 400 000	1 100 000	580 000

Figure.

P VIROT/WHO

Drug production in Addis Abada, Ethiopia

Figure.

P VIROT/WHO

Children talk about malaria during Gro Brundtland's visit to Nigeria, 2001