Slide 1

Win-Win or Lose-Lose?Why is multi-stakeholder involvement essential?

Saul Walker

Senior Health Advisor

UK Department for International Development

Slide 2

Overview

• Pharmaceutical sector goals in tension

• All stakeholders can be “irrational”

• Health sector weaknesses facilitate ‘irrational’ behaviour

• Complexity of system makes dynamic multi-stakeholder approach necessary

• No perfect resolution - can support more open, robust and accountable processes

Slide 3

What do we want to achieve in the pharmaceutical sector?

• Objectives can be in tension over time

• All stakeholders may hold beliefs that conflict with these objectives

• Relation to objectives dynamic and contextual

• Improved health outcomes• Patient (and provider) satisfaction• Equity

• Quality, safety and efficacy• Rational use and cost-effectiveness• Sustainability• Innovation

• Competitive markets?• Local industry?

Expanding Equitable Access

Available to the poor

Keeping Costs Affordable

To patient and to the health system

Effective interventionsLevels of care, innovation

4

Competing Pharmaceutical Policy Objectives?

Adapted from: Dennis Ross-Degnan (HMS)

Political cycles

Economic policies

External drivers

Organisational politics

Slide 5

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Consumers Providerspayments

treatment

Government (MOH)

info

rmat

ion

standards, payments

Drug Industry

standardslobbying

$$

mar

ketin

g promotion

oversight

Consumer Organizations

lobbying

support

informationstandards, education

Professional Organizations

lobbying

3rd Party Payers

payments payments, controls

coverageprice

informationinformation

Adapted from WHO

Slide 6

System weaknesses

• Inequitable financing– Inability to afford full courses or

purchase of low quality products

• Poorly designed payment systems – Incentives for over supply or high-

cost medicines

• Incentives/opportunities for diversion

– Salary supplementation– Weak LMIS to monitor products

• Weak information systems– Poor procurement and distribution– Limited use of evidence in planning

• Weak regulation– Inappropriate promotion of medicines– Low quality crowds out good quality

• Donor practice– Unpredictable financing, vertical

programmes and multiple missions

• Weak HR and Training– Poor practice, low consumer

confidence

Donors

Domestic political concernsRegulationsForeign/industrial policy

Pharmaceutical companies Profit focus (short/long) - marketingOpportunity costsIntellectual propertyStrategies for market share/volume

Wholesales, distributors, retailersProfit focus (short/long)Opportunity costsStrategies for market share/volume

International AgenciesProfile/fundingOverlapping agendasOrganisational structures/politicsPolitical outlook

Country GovernmentsLow budget allocationCompeting objectivesVested interestsPolitical outlook

People/Civil societyOverconsumption/self medicationPoor adherenceDisease specific groupsFunding/profile etcBelief systems

Potential for Poor Health Outcomes

Multi-stakeholder processes

• Clear goals and values–Health improvement, equity etc–e.g National Medicines Strategy, NICE

• Stakeholder positions and interests–politics and Politics

• Agree basic rules of the game–How debate takes place–Agree can disagree

Multi-stakeholder processes

• Improve information–Agreement on facts

• Identify opportunities for alignment–Win-wins (e.g quality)–Balance, persuade or overcome

• Think systems–A fix here, an unexpected consequence there

• Accountability – using information

Can’t align everyone, on everything all of the

time

Pharmaceutical companies Accurate information on pricingProactive roleBetter procurement and forecastingAchieve public health objectivesReduce pressure for inappropriate behaviour

Wholesales, distributors, retailersNew support for building capacityImproved market operationTackle corruption & wasteful practices

DonorsGood governance agendaIncrease access to medicinesSupport responsible businessIncrease aid effectiveness

International AgenciesGood governance agendaPromote ethical pharmaceutical procurement and supplyImprove health outcomes

Country GovernmentsDemonstrates commitment to good

governance – ↑ donor confidence Improved procurement and supplyBetter public health outcomes

Civil SocietyIncreased informationPlace at the tableSupportive environment for advocacyFinancial and other supportImproved dialogue with public and private sectors

Alignment on Transparency

Medicines Transparency Alliance

• Strengthen transparency and accountability through sharing robust data and multi-stakeholder working

• Seven pilot countries–Formed multi-stakeholder groups (Govt, private sector, civil society)–Agreed work plans focused on improving and sharing information–Completed baseline studies–Began to share information and develop policy options together

• 5 countries completed multi-sector working analyses– (www.medicinestransparency.org/meta-countries)

Slide 12

Medicines Transparency Alliance

• Multi-stakeholder working took time to develop

• Dynamics varied by country – strength of constituencies, familiarity with working together, priority issues

• Common issues: developing shared vision, ownership of processes, responsibilities, resourcing and communication

• Multi-stakeholder analysis – improvements in sector communication and participation, issue focused alliances

• Abstracts: 1108, 1025, 1013, 967

Medicines Transparency Alliance

• Phase 2 approved June 2011

• Can MeTA deliver more accountability and better health outcomes?

• Move from data collation to analysis and use – test strength of multi-stakeholder approach

• International secretariat role: WHO EMD and HAI Global

Source: Kerstens, Saad and Bannenberg (ICIUM 1108)

Slide 14

Questions

• How to build sufficient acceptance of basic rules?– Concept of conflict of interest in different cultures

• How to work in weak systems?– Lack of routine data, LMIS and regulatory capacity

• Can the complexity and dynamism of sector be managed?– Information desert to information overload

• How to balance short political timeframes and long solution lead-times?– Intermediate results, change management approaches

• How do we address the reality of power imbalances?– Governments, donors, companies, constituencies

Slide 15

Acknowledgements

Dr Tim Reed

Dr Michael Reich

Samia Saad

Dr Willbert Bannenberg

Dr Andreas Seiter

Dr Anita Wagner

Dr Dennis Ross-Degnan

MeTA team

Slide 16

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