Elsevier

Health Policy

Volume 121, Issue 7, July 2017, Pages 745-754
Health Policy

Are public-private partnerships the solution to tackle neglected tropical diseases? A systematic review of the literature

https://doi.org/10.1016/j.healthpol.2017.05.005Get rights and content

Highlights

  • Introduction to the market failure of neglected tropical diseases.

  • Assess the adequacy of public-private partnerships.

  • A mapping of public-private partnership(s) per disease.

  • No impact evaluation of public-private partnerships could be found.

  • The literature on public-private partnerships is mainly descriptive.

Abstract

Pharmaceutical companies are reluctant to invest in research and development (R&D) of products for neglected tropical diseases (NTDs) mainly due to the low ability-to-pay of health insurance systems and of potential consumers. The available preventive and curative interventions for NTDs mostly rely on old technologies and products that are often not adequate. Moreover, NTDs mostly affect populations living in remote rural areas and conflict zones, thereby hampering access to healthcare. The challenges posed by NTDs have led to the proliferation of a variety of public-private partnerships (PPPs) in the last decades. We conducted a systematic review to assess the functioning and impact of these partnerships on the development of and access to better technologies for NTDs. Our systematic review revealed a clear lack of empirical assessment of PPPs: we could not find any impact evaluation analyses, while these are crucial to realize the full potential of PPPs and to progress further towards NTDs elimination.

Introduction

Neglected tropical diseases (NTDs) are a diverse group of communicable diseases that affect more than one billion people, mainly across the developing world. The World Health Organization (WHO) lists 17 NTDs: Buruli Ulcer, Chagas disease, Dengue, Chikungunya, Dracunculiasis (guinea-worm disease), Echinococcosis, Endemic treponematoses, Yaws, Human African trypanosomiasis (sleeping sickness), Leishmaniasis, Leprosy, Hansen disease, Lymphatic filariasis, Onchorcerciasis (river blindness), Rabies, Schistosomiasis, Soil-transmitted helminthiases, Taeniasis, Cysticercosis, Trachoma [1]. It is common for people infected with NTDs to be hit by multiple pathogens; impairing physical and cognitive development, and leading to an estimated 534,000 death yearly [2]. These diseases were associated with 26.06 million disability adjusted-life years (DALYs) [3]. NTDs have a serious impact on work productivity: the largest of which seems to be due to blindness from onchocerciasis and severe manifestations of schistosomiasis [4]. Overall, these 17 diseases have been estimated to cost billions of dollars to developing economies each year [3].

The development of new treatments and vaccines cannot be incentivized through the usual patent system, for the ensuing reasons. First, the patent system grants monopoly power to pharmaceutical companies, usually for a period of 20 years, to encourage investment in research and development (R&D). The resulting lack of competition enables pharmaceutical companies to recoup R&D investment costs by setting a market price well above the marginal cost of production. Pharmaceutical companies are hence reluctant to invest in R&D for diseases that predominantly affect low and middle-income countries (LMICs) because of the health insurance system and consumers’ reduced ability-to-pay. Second, as LMICs are often characterized by poor local infrastructure and sanitation, lack of political commitment and bad governance in the health sector, lack of drug safety harmonization and weak legal frameworks, there can be no guarantee that a developed product will necessarily reach the population in need, thereby discouraging investment in R&D [5], [6], [7].

Translating this market failure into real facts, only five new therapeutic products were approved for NTDs between 2000 and 2011, accounting for less than 1% of the total products approved (i.e. 5 products out of 850). A significant share of the newly approved products instead targeted neuropsychiatric disorders (13%) and cardiovascular diseases (10%) [8]. This issue was pointed out by Bill Gates who, in 2008, called for “creative capitalism” [9], which include push, pull and mixed (push-pull) schemes. Push schemes reduce upfront costs inherent to R&D activities through various grants and subsidies offered prior to product discoveries – examples include R&D grants and direct funding. Pull schemes, on the contrary, offer a variety of rewards that are contingent on successful product discoveries – examples include advance market commitment (AMC) and priority review voucher (PRV). Push, pull and mixed schemes offer avenues for PPPs to overcome the barriers to the development of products for NTDs.

In 2011, half of the 34 new formulations for NTDs in clinical development – of which 85% were in Phase 2 or 3 – were sponsored through PPPs, charities, foundations and philanthropic institutions [8]. PPPs, so far, have mainly used push schemes, with government (e.g. The United Kingdom Department for International Development) or philanthropic (e.g. Bill and Melinda Gates Foundation) bodies providing upfront financing for clinical trials. The role of PPPs mainly lies in product development (PDPs; e.g. The Drug for Neglected Disease Initiative (DNDi)) and in product delivery and uptake (Access PPPs; e.g. The Onchocerciasis Control Program (OCP)). Other types of PPPs include financing and coordinating partnerships [10]. The different types of partnerships are not mutually exclusive: while it is more common for partnerships to dedicate themselves to one particular role, some use a hybrid model [10].

Tackling NTDs has become a major goal subscribed by the international community: the London Declaration – signed in 2012 – aims to reach the control or elimination of at least 10 NTDs by 2020 [11]. Various PPPs, with differing models, have hence been put in place to achieve this objective [12]. These have expanded over the past 20 years, and for some, the impacts are now measurable. Accordingly, we believe that it is now within researchers’ reach to assess the effectiveness and impact of these alliances. We thus conducted this review to respectively: (i) assess the scientific opinion on the adequacy and viability of PPPs; (ii) identify potential best mechanism(s) between push, pull and mixed ones; (iii) map the different partnerships and analyze their role in reaching the globally set goal to control, eliminate or eradicate NTDs.

Section snippets

Search strategy and selection criteria

A systematic literature search on PPPs for NTDs was performed over three databases: a general (Scopus), a bio-medical (PubMed) and an economic (IDEAS – Research Papers in Economics, REPEC) database. The search was conducted over three different databases to capture the multidisciplinary facets of PPPs. The REPEC database, for instance, enabled us to capture the economic perspective – a crucial feature – of PPPs and hence of the push, pull and hybrid mechanisms. In order to not discard any

Results

The search resulted in 198 non-duplicate articles, among which 6 could not be accessed. After abstract screening and full-text review, 74 articles were assessed eligible (cf. Fig. 1 for PRISMA diagram).

Discussion

The scientific literature on PPPs for NTDs is predominantly descriptive. An important part of the literature focuses on narrative descriptions of specific partnerships. A smaller but still significant share of the literature describes the different Schemes – push, pull and mixed Schemes – that can be used in a partnership. The striking point, however, is the small number of empirical studies: only 8 studies out of 74 had a research objective that was assessed through empirical investigation.

Ethical issues

There are no ethical issues.

Conflict of interest

There is no conflict of interest.

Acknowledgment

This project has received funding from the European Union’s Horizon 2020 research and innovation program under the Marie Sklodowska-Curie grant agreement N° 642609.

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