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Doi:10.1016/j.trstmh.2005.06.005

Transactions of the Royal Society of Tropical Medicine and Hygiene (2005) 99S, S1—S8
Public-private partnerships: an overview
Roy Widdus
Initiative on Public-Private Partnerships for Health (IPPPH), Global Forum for Health Research, Received 16June 2005; accepted 17 June 2005 The development and marketing of medicines needed specifically to combat diseases of the developing world are commercially unattractive because developing world; the populations concerned are among the poorest on earth. Partnerships which bring together pharmaceutical companies, academics, not-for-profit organizations, philanthropists, governmental and inter-governmental agencies are an increasingly Product development popular solution. These partnerships result in a complementarity of skills and resources that can accelerate the development and delivery of new medicines to those in need. Over the last 10 years or so, these public-private partnerships (PPPs) have grown significantly in number and diversity. However, they tend to Access public-private cluster into two main groups: those dealing with product development (PD PPPs), and those concerned with improving the access of new medicines to target pop- ulations (Access PPPs). The Initiative on Public-Private Partnerships for Health was set up four years ago to monitor the performance of these new partner- partnerships for health ships. After a series of studies of Access PPPs, it concluded that they provide significant benefits with very few side effects, particularly in the case of tropical 2005 Published by Elsevier Ltd on behalf of Royal Society of Tropical Medicine and portionately affect the poor' is perhaps a better Infectious and parasitic diseases remain a major In a vicious circle, poverty is a major cause of cause of death worldwide The so- health inequality in developing countries, and ill- called ‘neglected diseases' affect the very poor health perpetuates poverty. There are an estimated in particular and therefore ‘diseases that dispro- 11 million premature deaths per year in the world's poorest populations, and 80% of these are due to infectious diseases (In ∗ Present address: Global Futures Health Network, Interna- the age of globalization, many people still lack tional Center Cointrin, Entrance G, 3rd Floor, 20, route de Pr´e- access to essential medicines ( Bois, P.O. Box 1826, 1215 Geneva, Switzerland. Tel.: +41 22 799 4088; fax: +41 22 799 4089.
The UN Millennium Development Goals, adopted in September 2000, set targets for progress in 0035-9203/$ — see front matter 2005 Published by Elsevier Ltd on behalf of Royal Society of Tropical Medicine and Hygiene.

Figure 1 Many people still lack access to essential drugs.
tackling diseases of the developing world. These The reality for the poor of the developing world were to halt and begin to reverse the incidence is very different. Products developed for global use of HIV/AIDS, malaria and other major diseases by have a relatively slow introduction into poor coun- tries, usually caused by lack of planning and high At present, however, it is very doubtful that initial cost. Meanwhile, the development of prod- these targets can be achieved in most of the poorer ucts specifically needed to combat diseases dis- countries. The problem is that the array of ‘tools' proportionately affecting the poor has been sorely currently available to meet the international tar- neglected. Pharmaceutical companies are, after gets on child mortality, HIV/AIDS, tuberculosis (TB) all, commercial concerns with shareholders to con- and malaria are inadequate for the poorer coun- sider. New medicines are very expensive to develop.
Poor populations do not, by definition, provide a There are no vaccines against HIV infection or good return on this investment.
malaria and there is no vaccine to prevent the The solution to this deadly conundrum is ‘part- majority of TB cases (in adults). Existing diag- nership'. Public-private partnership (PPP) brings nostic tools or therapies for most diseases dis- together funders such as philanthropists and gov- proportionately affecting the poor are old and/or ernmental and inter-governmental agencies with difficult to use. First-generation vaccines against academics, industry and not-for-profit organiza- pneumococcal pneumonia may be too complex and expensive for use in developing countries. Vac- Public-private collaborations are needed to cines against rotavirus diarrhoea are only just tackle diseases of the developing world because emerging. Other childhood killers lack preven- no single sector — the for-profit private sector, tion. Most drugs are threatened by increasing the not-for-profit private sector or the govern- ment agencies of the public sector — has all the In an ideal situation, products developed for skills and resources needed to make an impact on global use move steadily along the research- its own. Independent efforts by the public sec- development-access continuum. Research is trans- tor or by non-governmental organizations (NGOs) lated into product concepts, these are devel- have mostly failed. Public-private partnerships, oped into proven products and manufacturing takes however, result in a complementarity of skills and place. The products go through regulatory approval resources that can accelerate the discovery, devel- to ensure consumer safety and are then introduced opment and delivery of new products to those in and used in well-functioning health systems.

2. Public-private partnerships — why
Over the last 10 years or so, PPPs have grown significantly in number and diversity (The Initiative on Public-Private Partnerships for Health The 1990s saw the emergence of a number of trends (IPPPH) was set up four years ago to undertake conducive to the establishment of PPPs.
long-term monitoring of PPP performance with the A systematic analysis of the global burden of dis- aim of recommending best practices. The IPPPH is ease highlighted ‘diseases associated with poverty' part of the Global Forum for Health Research, a and deficiencies in the tools to combat them.
small Swiss not-for-profit organization. The IPPPH is Pharmaceutical companies faced rising research funded by the World Bank, the Rockefeller Founda- and development (R&D) costs, consolidation and tion, the Gates Foundation and bilateral agencies.
greater competitive pressures. This increased their aversion to commercially risky or unattractive projects. Vaccines increasingly became ‘orphan' products despite their importance, especially in 3. Definition of a public-private
developing countries. Meanwhile, the HIV/AIDS pandemic drew global attention to the need for greater action on the health needs of low and Most PPPs comprise partners from three distinct middle income countries. Last but not least, pub- spheres. These are (i) the public sector, essen- lic sector and public interest organizations began tially governmental agencies and those institu- to realise that they could achieve a positive tions at the international level that are controlled health impact if they could find a way of tap- by governments, such as the WHO; (ii) the for- ping pharmaceutical industry skills and resources.
profit sector, which includes the pharmaceutical These factors, coupled with the emergence of dis- and biotech companies; and (iii) the civil society ease ‘champions' (see below) in the right place sector, which includes academia, non-profit mak- at the right time, have driven the growth of ing organizations such as NGOs and philanthropic The growth of PPPs has been helped by the estab- Public-private partnerships are not legally joint lishment of global coordinating and financing mech- ventures in the business sense. Rather, they are anisms such as the Global Alliance for Vaccines and joint ventures sharing a set of attributes, the most Immunization and the Vaccine Fund (GAVI/VF), Roll important of which is a shared objective. The moti- Back Malaria (RBM), the Stop TB Partnership and the vations of the partners vary, as do their contribu- Global Fund for AIDS, TB and Malaria. These create tions and benefits they expect to receive in return.
a significant ‘market' by funding the uptake of new Public-private partnerships involve shared decision making and risk taking.
Figure 3 Collaborative relationships between public and private sectors.
4. Public-private partnerships today
lowed and laid the groundwork for IAVI ( Today there are over 100 ventures involving phar- Medicines for Malaria Venture, founded in 1999, maceutical or other health sector companies that was the first drug development PPP. Two individ- can be described as PPPs. They are concerned with uals, Win Gutteridge and Robert Ridley, were the diverse topics including research, global coordi- ‘champions' here. Both had pharmaceutical indus- nation and financing mechanisms, health system try experience of product development and the strengthening, public education, advocacy and reg- portfolio approach. Gutteridge and Ridley initiated ulation, quality and standards. The majority, how- discussions between the Geneva-based Special Pro- ever, tend to cluster into two main groups: those gramme for Research and Training in Tropical Dis- dealing with the development of drugs and vac- eases (TDR), industry and malaria specialists. The cines, the so-called product development partner- new venture was supported by various other orga- ships (PD PPPs), and those concerned with improv- nizations, including the Rockefeller Foundation and ing access to medicines (Access PPPs). A third small the Global Forum for Health Research group, noted above, includes the global coordina- tion and financing mechanisms There are now some 20 PD PPPs. Some have only small portfolios. However, the older ventures have at least five or six years of operational experience 4.1. Public-private partnerships for product
and sizable portfolios. Their emergence was orig- inally fostered by the Rockefeller Foundation and subsequently by substantial funding from the Gates Public-private partnerships for the development of new products to combat diseases of the develop- Because of the variation among PD PPPs, they do ing world began to emerge in the mid-1990s. There not all work in an identical fashion, but there are had, of course, been earlier sporadic collabora- broad similarities which allow us to define a ‘typi- tion on an ad hoc basis around individual candidate cal' operation. All need to move candidate products products between public sector agencies and phar- through the R&D continuum as quickly and econom- ically as possible (They The new PD PPPs are different. Instead of taking may take on candidate products at any point in that a specific candidate product as their starting point, continuum. However, few PD PPPs fund activities these new partnerships survey the field and then translating basic research into candidate products.
promote the parallel development of a range of All candidate products must go through a num- different products. This ‘portfolio' approach, bor- ber of development stages requiring certain types rowed from the pharmaceutical and venture capital of testing. At the end of each stage, each candi- fields, is designed to manage the risk of failure date is re-assessed. Those with promise move on accompanying any individual project.
to the next stage, while those with problems such The first PD PPP addressing infectious diseases as low efficacy or toxicity are abandoned. Because was the International AIDS Vaccine Initiative (IAVI), so many drug candidates fail, it is cost-efficient to established in 1996. Some features of IAVI's and make the decision to abandon a project quickly.
Medicines for Malaria Venture's (MMV) approach can Public-private partnerships for product develop- be seen in the contraceptive field, around the mid- ment with a portfolio of candidate products at dif- 1990s (The IAVI was the ferent stages can routinely replace those that have brainchild of Seth Berkley, a public health epidemi- been terminated.
ologist with experience of the early HIV/AIDS epi- Each step of testing candidate drugs requires demic in Uganda. Berkley was then working at the both expertise and resources which may not exist Rockefeller Foundation. He realised that in order within the PD PPPs themselves: e.g. specialized to meet a global health need on this scale both laboratory equipment, animal models or access to philanthropic funding and industry expertise were human populations at risk of the target disease.
needed. He also saw that problems surrounding the Public-private partnerships for product develop- accessibility of new products to poor populations ment, unlike large pharmaceutical companies, do had to be addressed in order to achieve a significant not generally conduct all their activities ‘in house'.
health impact. Berkley persuaded the Rockefeller Instead they act as managers, bringing together Foundation to convene a meeting entitled ‘Accel- the needed expertise and resources in collabora- erating the development of preventive HIV vaccines tive project teams. These teams, drawn from phar- for the world'. Further meetings, co-sponsored by maceutical companies and other organizations, are the foundation and by the Fondation Merieux, fol- contracted to carry out specified testing steps in

Table 1 Diversity — the legal status of various partnerships addressing health problems
Downloaded from http://trstmh.oxfordjournals.org/ at Emory University on March 29, 2013 their own facilities, physically and organizationally In most cases, national programme managers distant from the PPP. This method, which requires dealt primarily with the WHO and had minimal lower investment in the PD PPP's own staff and contact with the participating pharmaceutical infrastructure and promotes flexibility, has come to companies. No specific challenges arose from the be known as ‘virtual R&D'.
involvement of the pharmaceutical companies.
By using collaborators, PD PPPs save time and In fact, there were several instances of benefits money, but pharmaceutical companies and other beyond the donation or discounting of drugs, e.g.
contributors also benefit in various ways. The aim in contributions to capacity building.
is to promote a ‘Win-Win' situation for everyone Governments and clinicians welcomed the drug concerned (see Nwaka, this supplement). ‘Virtual access PPPs. Without them, the countries stud- R&D' places extra management demands on the ied would generally struggle to afford the drugs.
PD PPP, but it is certainly cost-effective. A major The widely-held conclusion at country and global consultation in April 2004 concluded that the older level was that these drug access PPPs have assisted portfolio-based product development partnerships the poor to obtain necessary drugs. The studies using the collaborative approach had shown signs found no evidence of unreasonable conditionalities, of progress, but funding needed to be expanded impaired national ownership, distortion of national Although they draw upon or district priorities, or unhelpful reallocation of skills and procedures that are well established in human and financial resources at central, district the commercial sphere, these PD PPPs are essen- or community levels.
tially ‘social experiments'. ‘Best practices', proven However, the research showed that continued by the delivery of products, are not yet avail- support by donors in the maintenance as well as able. However, the development of comparative the intensive phases of elimination/control is vital performance measures will become necessary in if resurgence of disease is to be avoided. Likewise, the near future as judging ‘success' is important to Access PPPs must ensure that their operations are integrated with the district health system within disease-endemic countries from the outset. Fail- ure to do this resulted in the resurgence of African 4.2. Access public-private partnerships
trypanosomiasis (sleeping sickness) in Uganda when project staff withdrew after control was achieved.
These are partnerships addressing access to drugs In the case of donations or discounted pricing for in low to middle income countries. They are based access to HIV/AIDS drugs, where multiple play- on pharmaceutical industry donations or discounted ers or programmes existed, there was a need for pricing. Many are for tropical diseases and these more coordination and more support to countries, are often embedded within larger collaborations, particularly from international organizations, to sometimes for the elimination of a particular dis- reduce fragmentation and improve understanding Many of these access partnerships pre-date the emergence of the PD PPPs. It is not generally rec- ognized how successful the Access PPPs have been so far. The oldest, the Mectizan® donation pro- gramme for onchocerciasis (river blindness) in West Africa, has reached 40 million people in the last Over the last 10 or 15 years PPPs have made signif- decade. Meanwhile, GSK's donation of albenda- icant progress in tackling diseases that dispropor- zole within the Global Alliance for the Elimination tionately affect the poor.
of Lymphatic Filariasis (GAELF) reached 80 mil- The drug access PPPs, such as the Mectizan® lion people in 2003 alone, through mass community donation programme for onchocerciasis in West Africa and the donation of albendazole within A series of studies of access partnerships under- the GAELF, have already achieved, or are well taken by the IPPPH in Botswana, Sri Lanka, Uganda on the way to achieving, significant public health and Zambia in 2003—2004 impacts. They have helped the poor to access found that these PPPs have significant benefits with necessary drugs without distorting health priorities very few side effects, particularly in the case of at national or local level.
tropical diseases. The studies concluded that phar- Product development public-private partner- maceutical company involvement in tropical dis- ships, meanwhile, have made an impressive ease Access PPPs substantially improved drug avail- start since they began to emerge in the mid-1990s.
ability in the four study countries.
There are now significantly more projects underway aimed at developing new drugs to combat diseases Nwaka, S., Ridley, R., 2003. Virtual drug discovery and develop- associated with poverty. What sort of public health ment for neglected diseases through public-private partner- impact today's PD PPPs will eventually achieve, ships. Nat. Rev. Drug Discov. 2, 919—928.
only time can tell. However, for millions of the Ridley, R.G., Gutteridge, W.E., Currat, L.E., 1999. New medicines for malaria: A case study of the establishment of world's poorest people whose deadly afflictions a public/private sector partnership. Presented at 3rd Global have been ignored for so long, it is truly a great Forum for Health Research, Geneva.
step in the right direction.
Rockefeller Foundation, 1995a. Summary report and recommen- dation of an international ad hoc scientific committee. 27—28 October 1994. Le Val de Grˆace, Paris, France.
Rockefeller Foundation, 1995b. Summary report and recommen- dations of an international meeting: Financial and structural issues. 17 August 1995. New York.
Caines, K., Lush, L., 2004. Impact of Public-Private Partnerships Widdus, R., White, K., 2004. Combating Diseases Associated Addressing Access to Pharmaceuticals in Selected Low and with Poverty: Financing Strategies for Product Develop- Middle Income Countries: A Synthesis Report from Studies ment and the Potential Role of Public-Private Partner- in Botswana, Sri Lanka, Uganda and Zambia. Initiatives on ships. Initiative on Public-Private Partnerships for Health, Public-Private Partnerships for Health, Geneva.
Gwatkin, D., Guillot, M., 2000. The Burden of Disease among the WHO, 2004. World Health Report. World Health Organization, Global Poor. The World Bank, Washington, D.C., p. 44.

Source: http://web1.sph.emory.edu/users/hpacho2/PartnershipsMaize/Widdus_2005.pdf