Yet Another

In previous posts I have noted the proliferation of commissions, centers, institutes, and advisory groups which conduct numerous studies, analyses, and reviews and publish a host of reports, conclusions, summaries, and policy guidance in the name of improving global health, but mostly, it seems to me, aim to steer money to themselves and their pet programs.  Governments, international organizations, and foundations have been generous supporters of these august bodies over the years and continue to be so, and this cottage industry has grown to the extent we now have “think tanks” doing analyses on the previous crop of analyses.  I wonder if there has been a study to learn which of this output has resulted in a meaningful improvement in global health (hmm… maybe some foundation would like to fund me to do it).

A relatively new actor is the Results for Development Institute (R4D).  R4D, founded in 2007, is a Washington, DC, contract consulting firm with the mission “to spark innovative ideas and catalyze high impact actions that reduce poverty and improve lives in developing countries.”  More specifically, the Institute provides “policy analysis, critical information, decision-making tools, and policy advice to governments, civil society organizations, and international funders in order to stimulate positive change.”  The range of projects for which R4D has gotten funding is impressive, from assessing private health care in Ghana to monitoring developing countries’ government spending in the social sector.  Since most projects are still in progress, it is difficult for me (and maybe beyond my abilities) to draw a conclusion about their value, R4D seems to be tackling some tough and relevant nuts.  I’ve looked more closely at two.

In a post in September, I wrote about R4D’s Center for Health Market Innovations (CHMI), the core product of which is a database of mostly non-for-profit programs around the world which are implementing (mostly through grants) efforts to improve global health (the “innovations”).  The Center’s intent is also the “development of performance metrics” and to conduct “impact evaluations” (CHMI Approach).  As I wrote, this comparative data could be quite useful in finding “best practices” that could improve programs (if adopted, a big question) and, moreover, could identify programs that are sustainable beyond grants (and I would suspect are structured as for-[minimal]-profits).  My conclusion on CHMI was “So far so good,” but the Center needs more advisers with business experience so not to overlook the market-oriented “innovations.”

More recently, I have looked at the output of R4D’s Center for Global Health R and D Policy Assessment (CGHRDPA), which started in late 2009 with funding from (you guessed it) the Gates Foundation and whose mission is to “expand and improve the information used by governments, philanthropists and private investors in making decisions on new ways to drive global health R&D.”  I like the inclusion of “private investors” although wish to point out respectfully that the really big potential sources of expertise and investment in global health R&D are companies, so should not be overlooked.  Apparently, the Center is needed due to a proliferation of policy recommendations (by other centers, groups, institutes, and individuals) on neglected disease R and D funding.  Based on my reading of their first two draft reports, I’d say they are doing a good job in gathering useful information (especially through interviewing practitioners), a less-than-good job in looking broadly at the options (especially alternatives to grant/donor-based funding), and a weak job at drawing conclusions (but they are still in the draft stage).

The Center’s first two products are draft assessments of the utility of prizes and funds pooling in financing global health product development and are available for download and comments, both on their site and as written submissions (Draft Assessments).  After reading the first assessment, my skepticism in the prize approach was, if anything, strengthened.  While the authors’ draft conclusion is “Incentive prizes are an intriguing alternative to grants and other forms of push funding,” I think the intrigue results from a lack of understanding of the process of innovative (as opposed to incremental) product development and not looking at all the alternatives (a section to be completed in the next draft apparently).  To their credit, the authors cover many aspects of the prize concept and point out there may be better ways to accelerate product development (e.g., they mention regulatory harmonization, sample access, and joint clinical trials).  My net is that, while prizes may work to stimulate solutions when the problem is well-defined and the sponsors don’t specify how the solution will be implemented (which they can’t but do anyway), there are better ways, for example, through broadly dispersed early-stage investment and creating an assessable potential for future revenue.  But read the report and the submitted comments to decide on your own.

The second assessment is of three proposals to create “pooled funds,” i.e., essentially bureaucracies into which donors pore money which the bureaucrats dole out to deserving product developers, primarily the 16 or so product development programs (PDPs).  I commend the authors on the assessment’s thoroughness and was pleased to see that their research validated some of my biases, which I illustrate with the following selective (hopefully not-out-of-context) quotes:

  • “Funders did not have clear data on the nature of the problems in the global health product development system nor was there a consistent view of whether there is actually a funding shortfall, its likely extent or its timing.”  (Page 7).
  • “[W]hich problems, if solved, would give us the highest leverage to accelerate R&D for neglected diseases?   Through our interviews with over 50 experts, we found little consensus on the nature of the core problems or the relative importance of the problems.”  (Page 9)
  • “In interviews with donors and PDPs alike, coming to agreement on appropriate metrics on resource allocation – a critical dimension of each of the proposals – was identified as the single biggest challenge to the implementation of a pooled fund.”  (Page 9)
  • “An initial finding – and worth stating up front – is that the evidence base in terms of the performance of the current system against a number of crucial dimensions is weak. The implication of this is that if we do not know the extent of the current problems it becomes extremely difficult to assess the extent to which the proposals can address them. (Page 24, bolding in original; so the Center should figure out if/what the problems is first, before assessing solutions?)
  • “PDPs have their own priorities but there is no overall agreement on global priorities for neglected diseases R&D.  This raises a number of questions:  “Are the priorities set by PDPs sound?”  (Page 37)
  • “When industry analyses the candidate [drug]’s NPV [net present value], it factors in expectations about how existing products or other products in the pipeline will affect sales, what disease needs will be by the time the product is registered, and how the product life cycle will evolve once registered.  PDP insiders confide that PDPs are not engaging in this level of forward thinking about the product’s positioning and impact; rather the approach is ‘let’s get the product out and then we will see what we do with it’ ”.  (Page 44 where additional points on the weakness of PDP resource allocation are made)
  • “But many of these portfolio management challenges relate to more fundamental and difficult to solve problems of information and monitoring problems between donors and PDPs and incentives that naturally derive from the form of financing (i.e. grants, which reward effort and activity – not results).”  (Page 45)
  • The landscape is continually evolvingit is important that any approach does not simply address problems of the past.”  (Page 62, bolding in original).

Of especial interest to me are the sections that describe the potential role of the biotech/pharma industry (e.g., on emerging opportunities, page 78) and Appendix E “Product R&D for NTD and the pharma industry” (Pages 83-85).  The latter ends with:

In conclusion, the presence of the Pharma industry (particularly innovators) and public R&D networks addressing R&D for products for NTDs is in expansion, bringing forwards R&D capabilities and proprietary information as never before.  This is a unique opportunity to fulfill a gap that the public sector alone has not been able to address. If the PDPs (and their funders) are to play the role as mediators or brokers between the private and public sector, there might be a need to redesign the concept underlying PDPs.  Great attention will have to be given to disease priority setting, portfolio and project management across diseases and products, and creating an environment that is amenable (and not restrictive) for all parties -public or private- to provide the best of their competencies and capabilities towards creating product pipelines affordable and accessible that can be measured in the context of indicators such as those highlighted in the millennium development goals.

My net:  lots of food for thought and bases for important recommendations, and I appreciated the highlighting of the need to find ways to get for-profits more involved.  (Potential COI notice:  I, along with a gazillion others, applied for a recently advertised position with the CGHRDPA because I think they need more business-oriented input.)


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