Public-Private Partnerships for Heath Could Carve a New Path Forward for Epidemic Response
The following was written for the MSc Global Health Policy (Health Systems) Course at LSHTM and adapted for Medium.
Introduction
Private sector involvement in public health epidemic response is a highly contested topic and one worth discussing. Contested, partially due to private actors deemed to be making a profit off of the suffering of others (1). The private sector has been and continues to be involved in the health response to epidemics worldwide, however, their role is often not clear, making the process convoluted and slow. The situation is improving through the increased use of one type of Global Health Initiative (GHI) — Public-Private Partnerships for Health (PPPHs). Here it is argued the private sector, especially via PPPHs, should be more deeply involved in health system responses to epidemics due to the vital role they already employ, in every aspect of the health system. This will become evident through the challenges and lessons learned from the most recent Ebola Virus Disease (EVD) outbreak in Sub-Saharan Africa (SSA). From 2013 until the WHO declared its end in 2016 after 28,500 total cases, EVD claimed 11,300 lives (2). The WHO investigation that followed showed many areas for improvement. With further private sector involvement working alongside the government, the health outcomes, response speed, and efficiency have the potential for improvement and even radical progress.
To make this analysis, the WHO Health System Framework will be used as a reference of the aspects of the health system (Figure 1 and Table 1). Public and private sector boundaries must also be defined (Table 2). PPPHs are important here because they drastically changed the aid architecture of health development structure in the last 20 years (Table 2) (4).
Leadership/Governance
While the public sector is responsible for the governance surrounding health system response to epidemics, the private sector plays a significant role and could be involved in policy-making that leads to better regulation, incentives, and collaboration between the sectors (4). The WHO has acknowledged this in recent years, stating that the private sector has much to offer, especially the number of levers at their disposal (4). Yet, in most models made by the WHO showing governance roles and structure, the private sector is noticeably absent. This is inaccurate in terms of how governance realistically happens but also makes for confusing and disoriented partnerships, where if included, could become best practice (4). The WHO and MOH have an opportunity here to write policy with the private sector in mind, to provide more opportunities for them to participate and grow into a defined role. PPPHs are becoming a model for a successful partnership, but the model is still forming and there is an opportunity to define what this looks like and pursue further prospects to engage and innovate PPPHs (5–6).
The government response to the EVD epidemic was overwhelming, from SSA to the UK, USA, and Canada. However, the first discovery of EVD occurred in Guinea by an NGO, Médecins Sans Frontieres (MSF) (2). Similarly in Liberia, cases and the response was handled by a combination of sectors, including the WHO, CDC, UNICEF, and MSF. However, the Liberia outbreak was declared “relatively small” and therefore WHO and CDC decided to pull out, taking away valuable human resources and resources from the area, even with a reintroduction of the virus into one of the districts (2). MSF and Samaritan’s Purse continued to work on the outbreaks alongside the Liberian Government. It was clear there was no policy or leadership in place to guide these NGOs through this situation. Had there been, many deaths may have been prevented if the second wave could have been stopped short (2). PPPHs can be incredibly helpful in laying future plans for epidemic response, policy can be written which includes the private sector’s role so that the response can be efficient, and better outcomes can be more easily achieved.
Financing
It’s no secret that the public sector lacks funding for health. There are limited funds, and health is often one of the first cuts to be made, especially in LMIC. In epidemics, this situation is worsened by the acute needs placed on the health system, especially if it is not resilient (7). The private sector can create new mechanisms of funding that didn’t previously exist which can strengthen the health system and therefore the epidemic response (6).
During the EVD epidemic in Liberia, Sierra Leone, and Guinea funding was needed on many fronts (9). One of the main issues with the EVD outbreak in Sierra Leone was people not seeking treatment due to distrust of the healthcare providers (8). With proper training of community HCW, and funding of new interventions, this situation could have been avoided (8). PPPHs can be useful in providing a place for private sector investment to build up those resilient health systems with more potential to handle epidemics. Table 3 and Figure 2 illustrate this argument using the HAQ index which is associated with resiliency (7). With proper funding and investment from a PPPH, a resilient health system can be envisioned that allows for availability and purchasing of medical products and equipment, funding for HCW, and community outreach and engagement that produces effective contact tracing, surveillance, and health information dissemination (7).
Service Delivery / Health Workforce
While the private sector can play several roles in service delivery and the health workforce, where they really show the most impact is concerning epidemic response is scaling and filling in gaps. This was seen during the EVD epidemic when the WHO and CDC pulled out of Liberia leaving the NGOs to fill in and scale up their response (2). Another example of this was the importation of HCWs to the EVD response to SSA. The number of HCW was already sparse and many HCWs became ill. They also lacked facilities to deliver treatment. Such was the case in Sierra Leone, where more HCW became sick and died than in any other country (2). Save the Children and others worked alongside the governments of Sierra Leone, Canada, and the UK to fill in the gaps, create new ETCs, provide contact tracing and surveillance when the government was unable. They were also able to fill in the missing sectors of healthcare that the government is not able to focus on due to addressing the epidemic response, such as PHC, obstetric and pediatric care, mental health, elective services, etc. (10).
With further private sector partnership, the government would be able to carve out specific roles for both sectors, allowing them the workforce to provide the services they do to the best of their ability. Whereas usually there is an evasion of HCW due to life-threatening situations and limited resources available, a PPPH could also provide pull factors for HCW, which would incentivize them to stay during an unstable time. This, in turn, would allow for better service delivery.
Information
Access to information during an epidemic is crucial, but unfortunately due to infrastructure and other circumstances in some epidemic locations, not always realistic. The lack of physical and telecommunications infrastructure is one of the reasons why the dissemination of information was delayed during the EVD epidemic (2). With private sector involvement, through a PPPH with telecommunications companies in the case of an epidemic outbreak, this can be more easily managed short-term, while investments in roads, transportations, etc. can help in the long-term to bring about better overall health systems. There is also an opportunity here for collaborative learning and mutual gain, where the private sector can provide access to data and research that the public sector doesn’t have, brainpower from TENs networks, and even try to scale up research programs that will allow the public sector to grab more specific information that may be helpful when it comes to containing an epidemics; the private sector gains access to a larger population base and can work with instead of against the government on policies that help them facilitate their work (2).
Medical Products, Vaccines & Technologies
Medical Technology and Products is where the private sector is most visibly involved due to the high research and development (R&D) costs of things such as vaccines and other medical technology. Pharmaceutical companies aim to recuperate the costs of their investment upon sales of the medical product and due to this, vaccines, medications, and other products are usually priced very high until the patent is expired. However, increasingly companies are opting into PPPHs, due to many reasons including social responsibility and public perception (6).
Scientific progress is where the EVD epidemic in SSA saw much success, in great part due to PPPHs (2). Between the expansion for clinical trials, vaccines and treatment development and approval, rapid PRC testing, and real-time sequencing, the partnerships were solid and PPPHs played a huge role in this as many of the players were pharmaceutical and biotech companies(2).
The main PPPH was established in 2016 by pharmaceutical company Merck when they agreed to set aside a 300,000 dose stockpile of the, at the time, experimental vaccine, in case of emergency epidemics in exchange for Gavi committing to USD 5 million (11). Implementation and operational costs were taken care of by UNICEF, WHO, Gavi, MSF, and others (11). Another PPPH example is the clinical trials, where vaccine trials were being run simultaneously to the epidemic in Liberia. The governments of Liberia and the US signed a research partnership agreement in 2014 to begin Ebola vaccine trials (PREVAIL) (13), which included many private actors to aid in the logistics, management, and physical products. It also led to PREVAC which was another PPPH that included the likes of Johnson and Johnson, GSK, Merck, LSHTM, U of MN, HIC, and EVD-affected LMIC governments t0 work together to prevent the next EVD outbreak and respond quickly if it does happen (13).
Discussion
In LMIC, with low HAQ scores, the health systems are not prepared to handle the extra response needed. The private sector can provide significant human and material resources, funding, and information that can help to curb an epidemic and create a more resilient health system. With them playing such a large role in this response, it is wise that they be formally included within the policies that outline the overall epidemic response. Successful PPPHs can be used as a base to establish new and innovative partnerships in new ways throughout the health system.
Currently, a PPPH exists between pharma company Merck alongside, Gavi, WHO, UNICEF, MSF, and ICRC to keep a stockpile of Ebola vaccines for when epidemics happen (14–15). This allows any country at risk to be more agile in its response and cutting off future outbreaks early. Such is the case when a recent outbreak happened in DRC (16). However, PPPHs are not as common for health system infrastructure needs but should be considered due to success during epidemics to bring about better health outcomes, efficiency and lead to increased response times.
There are limitations to PPPHs, including but not limited to lack of empirical evidence to support success, lack of accountability, and possible corruption and conflicts of interest (6). However, the more studies that are done, the more promise they seem to hold (1). PPPH offers access and motivation for companies to invest in LMIC health more than previous partnerships, and often includes guidance or accountability from the public sector.
Conclusion
To summarize, there is a lack of strategy and faulty response to epidemics, like EVD, between the public and private sector due to challenging dynamics. And even though heavily involved in the response, the private sector is not written into policy surrounding epidemic response. PPPHs suggest a way forward to initiate strong partnerships that carve out roles for private sector actors that can help to alleviate the burden on the public sector whilst also helping to build up health system infrastructure in the long-term. More research needs to be done to determine the actual impact and sustainability of PPPHs. Still, like some existing and successful PPPHs, this could lead to better health outcomes, response times, and efficiencies amid an epidemic, while simultaneously creating more resilient health systems.
There are all sorts of partnerships and initiatives in global health for epidemic response. Do you think PPPHs work? What model do you find has worked best? Do you think there should be a mold so that actors and actions can fall into place or is that not possible due to the unpredictable nature and worldwide differences in response to different epidemics? Let me know what you think!
References
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