When Mike Crichton, Region Head (Asia Pacific, Middle East and Africa) of Sandoz – the generic medicines division of Novartis – takes the stage at a business conference at the Carlton Hotel in Singapore, a roomful of pharma executives, start-up founders, investors, NGO heads and journalists expect him to feed the session with tall ideas about the bottom-of-the-pyramid approach and its success metrics. Instead, he has emotional anecdotes from across the world. At one point, his eyes well up as he narrates the story of a woman in Indonesia suffering from cancer, at the brink of death because she could not afford the treatment. “She was the same age as my wife, and I was crying when I left the room that day,” he recounts.
Given big pharma’s hard positions on intellectual property and product pricing (which can often be predatory and cost lives), his emotional moment can come across as performative. The industry makes hundreds of billions of dollars in revenue every year even as millions die because they cannot afford healthcare, and yet they refuse to give in to some of the demands of governments and non-profits to enable better access to healthcare. But if he is indeed being genuine, then what must the pharma industry do to make us believe that they can do good too, that the private sector’s involvement in public health is not necessarily evil?
Harald Nusser, Head of Novartis Social Business, has an answer for that – they have to actually make people’s lives better, and that shouldn’t cost too much. “The pharma sector has been looked at critically, sometimes for good reasons, and sometimes for not so reasonable reasons. The question we are asking ourselves is, what makes us credible, and also act in a sustainable manner? It takes time and it is hard work to convince people, but ultimately, if we as a company contribute to make patients feel better, and they don’t find themselves below the poverty threshold for feeling better, then the word of mouth spreads.” And one of the ways, Novartis and several other stakeholders say, is to allow the private sector to work with governments through Private-Public-Partnership (PPP) models.
Profit motive and public health
At the conference exploring innovative solutions to bridge the unmet healthcare meets in Asia, Kimberly Green, Chief of Party for the PATH/USAID Health Markets project (PATH Mekong) says, “Non Communicable Diseases (NCDs) are the number one global killer, the majority of deaths occur in lower-and-middle-income countries. In Asia, 62% of deaths are attributable to NCDs, and certainly there is no solutions to NCDs without government working with the private sector, working with the community.” For many, the need for PPPs is a foregone conclusion.
In a seminar for the WHO, A Venkat Raman of the Faculty of Management Studies at the University of Delhi points how PPPs could be the justified response to the valid concerns over private sector’s involvement in public health. In an environment of extremely poor public healthcare system, the poor are forced to seek services from expensive private entities, thereby driving their out-of-pocket expenses. The rationale to collaborate, Raman points out, is that given their respective strengths and weaknesses, neither the public nor private sector can do the job alone.
There is also an increasing realisation among private sector leaders that they cannot replace the public healthcare system, and must instead improve access to it through their services. Speaking about their experience with the Arogya Parivar social business model in India, Deborah Gildea, Head of Novartis Social Business (Asia), says, “We are creating something by partnering with different organisations, with the belief that over time the public healthcare system is able to come into these communities. Our model will change and evolve to work alongside the government. We are looking to strengthen the system, not looking to create something separate.”
Even so, it has been noticed that PPPs are riddled with challenges and have not been performing well for the most part in India. Their poor track record is well-documented with several individual cases making the news every now and then. Bijoya Roy points out that the lack of implementation of quality control has led to a negative impact on patient care and workers’ rights. There are concerns over data sharing and an inflation of costs, and also how they are structurally designed to work against universality.
The private sector is not in a position to deny the criticism. But the response to it, many say, is not to do away with PPPs, but better processes and stronger individuals. A former CEO of a pharma multinational says, “PPPs and social business programs working with governments can do well, but it depends on the individuals leading the programs, both from the private and public side. If they are genuine, these programs can really help. But only if they are genuine, and there must be accountability.”
Mike Crichton echoed this sentiment later in his talk, “The sheer size of this challenge (access to healthcare) in Asia is immeasurable. I think the solutions are out there, you just need passionate committed people to go after them, and a strong leadership to make sure that they can deliver.”
Individuals in the government too have a role in that, says Nusser, “The most important things from my perspective are the willingness to step up to leadership positions as an individual or as a government, and secondly, allow the private sector to play their part and not be perceived as evil per se.” Novartis, Gildea says, is actively looking to seek out such individuals in the government system who are willing to work with them to improve public healthcare.
Not if, but how
On the sidelines of the conference, a public financing analyst says that PPPs are only as good as their contracts. He points to the example of a partnership between a private hospital chain and the Maharashtra government, which has just a 6-page contract, has political motivations, is ambiguous on payments for medicines and allied services and does not deal with property tax issues. All these factors have collectively led to the failure of the PPP, he adds. Dhawal Jhamb, Lead for Health PPP Projects, International Finance Corporation, World Bank Group, says that some of the challenges of PPPs can be solved just by a good contract.
Raman also points out that not all interactions can become PPPs. They need to have clear terms and conditions, clear partner obligations and performance indicators, stipulated time period and overall health objectives.
Jhamb says, “Most of the PPP policies for healthcare are focussed on investment into healthcare and not service delivery or service outcomes.”
“By partnering with the services of health and educating the patients directly in the local communities, we are able to work in partnership with the government to strengthen the primary healthcare system,” he adds.
Jhamb and several others also point out that bureaucrats need to step up, and there are signs of it. “We are starting to have some interesting engagements with some of the state governments around how we will be able to partner with them, with other programs like Novartis Access and the health and well-being centres opened by the government,” says Gildea.
Lokesh Kumar, Country Head of Novartis Social Business India, seconds that, with learnings from the Arogya Parivar experience. “The kind of work that we have been putting in in these villages (Where Novartis Arogya Parivar programs run) have become a big hit. We got the recognition we deserve. I wouldn’t say we would be able to replace the government system, I don’t think it is possible. But we have been able to supplement and complement what the government has been doing. The governments are encouraging us to expand.”
Nusser however points out that the pharma sector alone cannot work any wonders, “Let me be clear about one thing, public health is predominantly something for the public to solve, he says, “Ultimately, public health system and building the infrastructure for it is not the responsibility solely for the pharmaceutical industry to solve, but we have a role to play clearly, and others like insurers and service-delivery organisations like hospitals or hospital chains.”