Mectizan Donation Program: evaluation of a public-private partnership

Insights for the future of health system partnerships in low- and middle-income countries: a systematic literature review

BACKGROUND

Despite growing support for the private sector involvement in the provision of public health services in Low- and Middle-Income Countries (LMICs), a lack of clear information on the future of the provision of such services restricts the ability of managers and policy-makers to assess how feasible integration between public and private actors may be in these countries. This paper presents a systematic literature review which traces the dynamics and boundaries of public-private partnerships for the healthcare sector in LMICs.

METHODS

A total of 723 articles indexed in Scopus were initially submitted to bibliometric analysis. Finally, 148 articles published in several academic journals were selected for independent full-text review by two researchers. Content analysis was made in order to minimise mistakes in interpreting the findings of studies in the sample.

RESULTS

Public-private partnerships identified through the content analysis were categorised into four research areas: 1) Transfer of resources; 2) Co-production of health goods and services; 3) Governance networks; 4) Criteria for successful partnership development.

CONCLUSIONS

The four main research areas supply suggestions for a future research agenda, and managerial and policy implications for partnerships in LMICs.

Evaluation of pharmaceutical industry-led access programmes: a standardised framework

Pharmaceutical industry-led access programmes are increasing in number and scope worldwide. We present a new standardised framework for evaluation of these programmes that includes three components: a taxonomy of 11 access programme strategies; a series of logic models, one for each strategy and a set of measurement indicators. The logic models describe pathways of potential programme impact. Concepts relevant across a broad range of strategies were prioritised for inclusion in logic models to ensure consistency and to facilitate synthesis and learning across programmes. Each concept has at least one corresponding measurement indicator with metadata that includes the definition, details on how it should be measured and recommended data sources. The framework establishes a shared language for the collection and reporting of meaningful industry-led access programme information. Broad adoption by programme developers and implementing partners in the for-profit sector and beyond could facilitate shared learning on effective strategies and best practices.

Public-private partnership (PPP) development: Toward building a PPP framework for healthy eating

Public-private partnerships (PPPs) in public health have gained great attention in the global health literature over the last two decades. Evidence suggests that PPPs could contribute to mitigating complex health problems. There is, however, limited knowledge about the process and specific conditions in which PPPs for healthy eating, in particular, can be developed successfully. To address this gap, this article first summarizes the literature, and second, using qualitative content analysis, identifies factors deemed to influence the process of building PPPs for healthy eating. The literature search was undertaken in two stages. The first stage focused on PPPs in public health to understand what constitutes a PPP, and the types and characteristics of PPPs. The second stage sought empirical examples and conceptual papers related to PPPs for healthy eating to identify critical elements that could facilitate or hinder partnerships between the government and the food industry. The search yielded 38 articles on PPPs in public health and 20 on PPPs for healthy eating. The analysis generated 23 individual elements that have the potential to influence a successful process of building PPPs for healthy eating (eg, endorsement from an individual champion, equal representation from partner organizations on board committees). The analysis also yielded five factors that appeared to well-represent the 23 individual elements of PPP formation: motivation, enablers, governance, benefits, and barriers. These results constitute an important step to understand critical factors involved in the formation of PPPs in public health and should inform additional empirical research to validate them.

Intersectoral collaboration for the prevention and control of vector borne diseases to support the implementation of a global strategy: A systematic review

Introduction

Vector Borne Diseases (VBDs) have a major impact on public health and socio-economic development. Inter-sectoral collaboration was recommended as one of the key elements of Integrated Vector Management (IVM), however limited evidence measures the effect and contribution of intersectoral approaches including but not only IVM. This systematic review aims to assess the existing evidence on all forms of inter-sectoral collaboration in VBD control and prevention, identify any gaps and develop a framework from a global perspective.

Methods

Articles were identified through a search of PUBMED, Science of Direct, Web of Knowledge, Google Scholar and WHO archives using key words and excluded duplications (n = 2,034). The exclusion of non-VBDs control and prevention interventions resulted in 194 eligible titles/abstract/keywords for full text assessment. Further exclusion of non-peer reviewed articles, non-declaration of ethical clearance, reviews and expert opinion articles resulted in 50 articles finally being included for analysis with the extraction of data on outcome, factor/s influencing the effectiveness, indicators of collaboration and sustainability.

Results

Of the 50 articles included in the analysis, 19 articles were categorized as of moderate-strong quality. All articles compared pre- and post-intervention outcomes against disease or vector variables. Three papers included outcome variables on intersectoral collaboration and participation indicator. However, no paper undertook component analysis by different sectors or different activities. Only one paper compared cost data for community-intersectoral intervention for IRS and traditional “vertical” IRS. Six factors were identified as influencing the effectiveness of inter-sectoral collaboration. Five of six factors are the main ones, namely the approach (37/47), resources (34/47), relationships (33/47), management (29/47) and shared vision (20/47) factors. A conceptual framework has been developed based on this review.

Conclusion

This review shows the importance of inter-sectoral collaboration to reduce VBDs or vector densities. However, very few studies measured how much inter-sectoral collaboration contributes to the impact. Further high-quality studies using inter-sectoral collaboration indicators are recommended to be undertaken.

Investigating Private Sectors’ Behavioral Intention to Participate in PPP Projects: An Empirical Examination Based on the Theory of Planned Behavior

The active involvement of private sectors in Public-Private-Partnership (PPP) projects is critical for sustainable development of the PPP mode. While there have been many studies on PPP in the literature, limited research has been conducted to investigate the critical factors that affect the intention of the private sector to participate in PPP projects. To bridge the knowledge gap, this study proposed a theoretical model based upon the theory of planned behavior (TPB), and then tested it based upon empirical data collected from China. Partial least squares structural equation modeling (PLS-SEM) was employed in testing the model. Results indicated that “perceived behavioral control”, “governmental influence”, and “private sectors’ attitude toward PPP” were the three most significant latent variables affecting the intention of private sectors to participate in PPP projects; and “financial capability”, “full compliance with PPP contracts”, and “profitability” were the three most significant observable variables affecting the intention of the private sector. The research findings contribute to the body of knowledge about private sector involvement in PPP projects in a Chinese context, and also provide solid support for the government to issue relevant polices or undertake reforms to attract more private sectors to participate in the PPP projects.

Review on medicinal plants and natural compounds as anti-Onchocerca agents

Onchocerciasis is a filarial vector borne disease which affects several million people mostly in Africa. The therapeutic approach of its control was based on a succession of drugs which always showed limits. The last one: ivermectin is not the least. It was shown to be only microfilaricidal and induced resistance to the human parasite Onchocerca volvulus. The approach using medicinal plants used in traditional medicine is a possible alternative method to cure onchocerciasis. Onchocerca ochengi and Onchocerca gutturosa are the parasite models used to assess anthelmintic activity of potentially anthelmintic plants. Numerous studies assessed the in vitro and/or in vivo anthelmintic activity of medicinal plants. Online electronic databases were consulted to gather publications on in vitro and in vivo studies of anti-Onchocerca activity of plants from 1990 to 2017. Globally, 13 plant families were investigated for anti-Onchocerca activity in 13 studies. The most active species were Anacardium occidentale, Euphorbia hirta and Acacia nilotica each with an LC₅₀ value of 2.76, 6.25 and 1.2 μg/mL, respectively. Polycarpol, voacamine, voacangine, ellagic acid, gallic acid, gentisic acid, 3-O-acetyl aleuritolic acid and (-)-epigallocatechin 3-O-gallate were the isolated plant compounds with anti-Onchocerca activity. Most of the assessed extract/compounds showed a good safety after in vivo acute toxicity assays and/or in vitro cytotoxicity test. The exception was the ethanol extract of Trichilia emetica, which killed completely and drastically mice at a dose of 3000 mg/kg. Several plant groups of compounds were shown active against Onchocerca sp. such as tannins, alkaloids, triterpenoids and essential oils. Nevertheless, none of the active compounds was subjected to clinical trial, to assessment of its diffusibility through nodular wall or its capability to induce genetic resistance of Onchocerca sp.

Onchocerca volvulus infection in Tihama region - west of Yemen: Continuing transmission in ivermectin-targeted endemic foci and unveiled endemicity in districts with previously unknown status

Background

Onchocerciasis in Yemen is one of the most neglected diseases, where baseline estimates of onchocerciasis and monitoring of the impact of ivermectin regularly administered to the affected individuals on its transmission are lacking. Therefore, this study aimed to determine the anti-Ov16 IgG4 seroprevalence among local communities of Hodeidah and Al-Mahwit governorates of Tihama region. The factors possibly associated with previous exposure to infection were also studied.

Methodology/Principal findings

This cross-sectional study was conducted in two ivermectin-targeted districts endemic for onchocerciasis in Hodeidah and Al-Mahwit and two untargeted districts with unknown previous endemicity in Hodeidah between February and July 2017. For 508 residents sampled by a multi-stage random approach, data were collected and blood specimens were screened for anti-Ov16 IgG4 using the SD BIOLINE Onchocerciasis IgG4 rapid tests. The study revealed an overall anti-Ov16 IgG4 rate of 18.5% (94/508) in all surveyed districts, with 10.2% (12/118) of children aged ≤10 years being seropositive. Moreover, rates of 8.0% (4/50) and 6.1% (4/66) were found in districts not officially listed as endemic for the disease. Multivariable analysis confirmed the age of more than ten years and residing within a large family as the independent predictors of exposure to infection.

Conclusions/Significance

Onchocerciasis transmission is still ongoing as supported by the higher anti-Ov16 IgG4 seroprevalence rate among children aged ≤10 years compared to that (<0.1%) previously set by the World Health Organization as a serologic criterion for transmission interruption. Further large-scale studies combining serologic and entomologic criteria are recommended for the mapping of O. volvulus in human and blackfly populations in endemic foci and their neighboring areas of uncertain endemicity. In addition, ivermectin distribution, coverage and impact on disease transmission need to be continually assessed.

Onchocerciasis is endemic in certain foci in the western governorates of Yemen. Monitoring the impact of the regular ivermectin administration to affected individuals on the transmission status and providing baseline onchocerciasis estimates in endemic areas are crucial for planning effective elimination strategies. We found that the disease transmission is still ongoing in Hodeidah and Al-Mahwit governorates of Tihama region as indicated by the anti-Ov16 IgG4 seropositivity among children aged ≤10 years. In Bani Sa'ad, where affected individuals had been regularly targeted with ivermectin over the last 15 years, we found that the anti-Ov16 IgG4 seroprevalence rate was significantly lower among children aged ≤10 years (9.1%; 5/55) compared to those >10 years (24.5%; 37/151), reflecting a possible decline in disease transmission. We also revealed onchocerciasis transmission in districts with unknown previous endemicity for the first time, with rates of 8.0% and 6.1% being found in Al Marawi'ah and As Sukhnah districts of Hodeidah. Large-scale surveys are recommended for mapping of O. volvulus in human and blackfly populations in endemic foci and neighboring untargeted areas of uncertain endemicity as a forward step towards the elimination of the disease from the country.

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

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.

Assessment of the scope and practice of evaluation among medical donation programs

Background

Medical donation programs for drugs, other medical products, training and other supportive services can improve access to essential medicines in low- and middle-income countries (LMICs) and provide emergency and disaster relief. The scope and extent to which medical donation programs evaluate their impact on recipients and health systems is not well documented.

Methods

We conducted a survey of the member organizations of the Partnership for Quality Medical Donations (PQMD), a global alliance of non-profit and corporate organizations, to identify evaluations conducted in conjunction with donation programs.

Results

Twenty-five out of the 36 PQMD organizations that were members at the time of the survey participated in the study, for a response rate of 69 %. PQMD members provided information on 34 of their major medical donation programs. Half of the donation programs reported conducting trainings as a part of their donation program. Twenty-six (76 %) programs reported that they conduct routine monitoring of their donation programs. Less than 30 % of donation programs were evaluated for their impact on health. Lack of technical staff and lack of funding were reported as key barriers to conducting impact evaluations.

Conclusions

Member organizations of PQMD provide a broad range of medical donations, targeting a wide range of public health issues and events. While some level of monitoring and evaluation was conducted in nearly 80 % of the donation programs, a program’s impact was infrequently evaluated. Opportunities exist to develop consistent metrics for medical donation programs, develop a common framework for impact evaluations, and advocate for data collection and analysis plans that collect meaningful metrics.

Doing well while fighting river blindness: the alignment of a corporate drug donation programme with responsibilities to shareholders

OBJECTIVE

Using the example of Merck's donations of ivermectin, to show how tax incentives and non-profit collaborators can make corporate largesse consistent with obligations to maximise returns to shareholders.

METHODS

We obtained information from publicly available data and estimated Merck's tax deductions according to the US Internal Revenue Code. Reviews of Merck-Kitasato contracts and personal interviews provided additional information regarding key lessons from this collaboration.

RESULTS

Our best estimate of the direct cost to Merck of the ivermectin tablets donated during 2005-2011 is around US$ 600 million, well below the stated value of US$ 3.8 billion. Our calculation of tax write-offs reduces the net cost to around US$ 180 million in that period. Indirect market benefits and effects on goodwill further enhanced the compatibility of Merck's donation programme with the company's profit-maximising objective. The case offers lessons for effective management of collaborations with public and non-profit organisations.

CONCLUSION

Merck's role in the donation of ivermectin for the treatment of onchocerciasis is widely and justly acknowledged as a prime example of corporate largesse in the public interest. It is nevertheless important to note that several public and non-profit collaborators, and United States taxpayers, played significant roles in increasing Merck's incentives, and indeed ability, to conduct the donation programme that changed so many lives in poor countries, while meeting its responsibilities to shareholders. Overall, the record indicates responsible corporate management of Merck's ivermectin programme and demonstrates the feasibility of socially responsible policies in a manner compatible with obligations to shareholders.

Public-private partnership as a solution for integrating genetic services into health care of countries with low and middle incomes

In recent years scientific progress has dramatically raised the potential of genetic services, but the actual benefits of these developments are not universally shared. In countries of low and middle incomes, improvements in genetic services frequently lag behind. Since this is generally caused by lack of resources and not by the lack of political will, the question arises, how can one most easily acquire the necessary capital to improve the health care in these areas. Public-private partnerships (PPPs) offer one approach to solve this issue, aiming at the inclusion of private enterprises in the realisation of public authority services. So far PPPs have been used exclusively in other health service areas. In this paper a first attempt is being made to discuss the feasibility of transferring the concept of PPP to genetic services, and consideration is given as to where the most promising starting point might be. We start by defining a multilevel structure that needs to be considered in providing comprehensive genetic care. We continue by explaining the concept of PPPs and their current types of implementation in medical services. We then examine how the PPP model could be applied to genetic services or sections thereof. We arrive at the conclusion that a likely starting point for PPP in genetic services is at the level of the infrastructure building service.

Important helminth infections in Southeast Asia diversity, potential for control and prospects for elimination

Besides the 'big three'-HIV/AIDS, malaria and tuberculosis-there are a host of diseases that, by comparison, are truly neglected. These so-called neglected tropical diseases (NTDs), many of which caused by helminths, are intimately linked with poverty and are rampant where housing is poor; access to clean water and adequate sanitation is lacking; hygiene and nutrition is substandard and populations are marginalized and vulnerable. More than a billion people are affected by NTDs, mainly in remote rural and deprived urban settings of the developing world. An overview of papers published in two special thematic volumes of the Advances in Parasitology is provided here under the umbrella of current status of research and control of important helminth infections. A total of 25 comprehensive reviews are presented, which summarise the latest available data pertaining to the diagnosis, epidemiology, pathogenesis, prevention, treatment, control and eventual elimination of NTDs in Southeast Asia and neighbourhood countries. The focus of the first volume provides the current regional status of schistosomiasis, lymphatic filariasis, food-borne trematodiases, echinococcosis and cysticercosis/taeniasis, less common parasitic diseases that can cause epidemic outbreaks and helminth infections affecting the central nervous system. The second volume deals with the tools and strategies for control, including diagnostics, drugs, vaccines and cutting-edge basic research (e.g. the '-omics' sciences). Moreover, cross-cutting themes such as multiparasitism, social sciences, capacity strengthening, geospatial health technologies, health metrics and modelling the potential impact of climate change on helminthic diseases are discussed. Hopefully, these two volumes will become useful for researchers and, most importantly, disease control managers for integrated and sustainable control, rigorous monitoring and eventual elimination of NTDs in Southeast Asia and elsewhere.

Application of nanotechnologies for improved immune response against infectious diseases in the developing world

There is an urgent need for new strategies to combat infectious diseases in developing countries. Many pathogens have evolved to elude immunity and this has limited the utility of current therapies. Additionally, the emergence of co-infections and drug resistant pathogens has increased the need for advanced therapeutic and diagnostic strategies. These challenges can be addressed with therapies that boost the quality and magnitude of an immune response in a predictable, designable fashion that can be applied for wide-spread use. Here, we discuss how biomaterials and specifically nanoscale delivery vehicles can be used to modify and improve the immune system response against infectious diseases. Immunotherapy of infectious disease is the enhancement or modulation of the immune system response to more effectively prevent or clear pathogen infection. Nanoscale vehicles are particularly adept at facilitating immunotherapeutic approaches because they can be engineered to have different physical properties, encapsulated agents, and surface ligands. Additionally, nanoscaled point-of-care diagnostics offer new alternatives for portable and sensitive health monitoring that can guide the use of nanoscale immunotherapies. By exploiting the unique tunability of nanoscale biomaterials to activate, shape, and detect immune system effector function, it may be possible in the near future to generate practical strategies for the prevention and treatment of infectious diseases in the developing world.

Programmes, partnerships, and governance for elimination and control of neglected tropical diseases

Neglected tropical diseases represent one of the most serious burdens to public health. Many can be treated cost-effectively, yet they have been largely ignored on the global health policy agenda until recently. In this first paper in the Series we review the fragmented structure of elimination and control programmes for these diseases, starting with the ambiguous definition of a neglected tropical disease. We describe selected international control initiatives and present their effect, governance arrangements, and financing mechanisms, including substantial drug-donation programmes. We also discuss efforts to exploit shared features of these diseases by integration of selected control activities within countries, thus creating economies of scope. Finally we address the challenges, resulting from the diversity of disease control approaches and governance structures-both nationally and internationally-and provide some suggestions for the way forward.

The effects of global health initiatives on country health systems: a review of the evidence from HIV/AIDS control

This paper reviews country-level evidence about the impact of global health initiatives (GHIs), which have had profound effects on recipient country health systems in middle and low income countries. We have selected three initiatives that account for an estimated two-thirds of external funding earmarked for HIV/AIDS control in resource-poor countries: the Global Fund to Fight AIDS, TB and Malaria, the World Bank Multi-country AIDS Program (MAP) and the US President's Emergency Plan for AIDS Relief (PEPFAR). This paper draws on 31 original country-specific and cross-country articles and reports, based on country-level fieldwork conducted between 2002 and 2007. Positive effects have included a rapid scale-up in HIV/AIDS service delivery, greater stakeholder participation, and channelling of funds to non-governmental stakeholders, mainly NGOs and faith-based bodies. Negative effects include distortion of recipient countries' national policies, notably through distracting governments from coordinated efforts to strengthen health systems and re-verticalization of planning, management and monitoring and evaluation systems. Sub-national and district studies are needed to assess the degree to which GHIs are learning to align with and build the capacities of countries to respond to HIV/AIDS; whether marginalized populations access and benefit from GHI-funded programmes; and about the cost-effectiveness and long-term sustainability of the HIV and AIDS programmes funded by the GHIs. Three multi-country sets of evaluations, which will be reporting in 2009, will answer some of these questions.

Orphan drug legislation: lessons for neglected tropical diseases

In the last 20 years, orphan drug legislation (ODL) has been adopted in several countries around the world (USA, Japan, Australia, and the European Union) and has successfully promoted R&D investments to develop new pharmaceutical products for the treatment of rare diseases. Without these incentives, many life-saving new drugs would have not been developed and produced. For economic reasons, the development of medicines for the treatment of diseases prevalent in the developing world (or tropical diseases) is lagging behind. Among several factors, the low average per-capita income makes pharmaceutical markets in developing countries appear relatively unprofitable and therefore unattractive for R&D-oriented companies. The case of ODL may offer some useful insights and perspectives for the fight against neglected tropical diseases. First, the measures used in ODL may also be effective in boosting R&D for neglected tropical diseases, if appropriately adapted to this market. Second, small-sized companies, which have played a successful role in the development of orphan drugs for rare diseases, may also represent a good business strategy for the case of tropical diseases.

Global health partnerships in practice: taking stock of the GAVI Alliance's new investment in health systems strengthening

Despite a burgeoning literature on global health partnerships (GHPs), there have been few studies of how GHPs, particularly those trying to build a bridge between horizontal and vertical modes of delivering essential health services, operate at global and country levels. This paper will help address this knowledge gap by describing and analyzing the GAVI Alliance's early experience with health systems strengthening (HSS) to improve immunization coverage and other maternal-child health outcomes. To date, the strengths of HSS reside in its potential to optimize GAVI's overall investment in immunization, efforts to harmonize with other initiatives, willingness to acknowledge risk and identify mitigation strategies, engagement of diverse stakeholders, responsiveness to country needs, and effective management of an ambitious grant-making enterprise. The challenges have been forging a common vision and approach, governance, balancing pressure to move money with incremental learning, managing partner roles and relationships, managing the "value for money" risk, and capacity building. This mid-point stock-taking makes recommendations for moving GAVI forward in a thoughtful manner. The findings should be of interest to other GHPs because of their larger significance. This is a story about how a successful alliance that decided to broaden its mandate has responded to the technical, organizational, and political complexities that challenge its traditional business model.

Operational lessons from 20 years of the Mectizan Donation Program for the control of onchocerciasis

The donation of ivermectin (Mectizan, Merck & Co., Inc.) to control onchocerciasis (river blindness) was established in 1987 and has since gradually expanded to provide for >570 million treatments cumulatively over the past 20 years. The Mectizan Donation Program (MDP) operates within a broad partnership in 33 endemic countries in need of mass treatment. Particular operational methods and tools are applied to facilitate ivermectin mass treatment. Drug management has been streamlined, including dosing, tablet size and packaging, and monitoring for adverse events. Much of the experience gained in the development of ivermectin mass treatment can be usefully applied in the recent broader perspective of control of neglected tropical diseases. The most important operational lessons of the MDP include: (i) the need to easily define the target population for treatment using rapid, non-invasive techniques; (ii) the value of a broad partnership; (iii) the great potential of working through community-directed treatment; (iv) the need to streamline all drug management aspects and (v) the importance of operations research to tackle new challenges.

Optimizing in-kind drug donations for Tanzania-a case study

A questionnaire survey (QS) among stakeholders in Tanzania had shown that in-kind drug donations (DDs) are important to boost the drug supply system. Major problems were their insufficient quantity for sustainable treatment and the discrepancy between the needs of the recipients and the donors' supply. Objectives in this study were to discuss these findings and to learn from key informants (KIs) how to improve the DD process. Data were collected through KI interviews in 2001/2002.A 30% gap in drug supply has to be bridged by DDs. KIs confirmed the importance of the World Health Organisation and Tanzanian DD guidelines as a tool for good donation practice and emphasized the role of the government in their implementation. They requested that donors meet the recipient country's regulatory requirements. In contrast to QS respondents, KIs did not view DD quality as a minor problem, and proposed that DD quality should be adapted to the national quality assurance procedures. DD processes could be improved through (a) effective implementation of DD guidelines as an aid for decision-making and for quality assurance, (b) availability of data to improve communication between donors and recipients, (c) transparency between recipients and donors and (d) clearly defined accountability.

Neglected diseases, civil conflicts, and the right to health

Neglected diseases remain one of the largest causes of disease and mortality. In addition to the difficulties in provision of appropriate drugs for specific diseases, many other factors contribute to the prevalence of such diseases and the difficulties in reducing their burden. We address the role that poor governance and politically motivated oppression have on the epidemiology of neglected diseases. We give case examples including filariasis in eastern Burma and vector-borne diseases (Chagas' disease, leishmaniasis, and yellow fever) in Colombia, we show the links between systematic human rights violations and the effects of infectious disease on health. We also discuss the role of researchers in advocating for and researching within oppressed populations.

Public-private partnerships to build human capacity in low income countries: findings from the Pfizer program

BACKGROUND

The ability of health organizations in developing countries to expand access to quality services depends in large part on organizational and human capacity. Capacity building includes professional development of staff, as well as efforts to create working environments conducive to high levels of performance. The current study evaluated an approach to public-private partnership where corporate volunteers give technical assistance to improve organizational and staff performance. From 2003 to 2005, the Pfizer Global Health Fellows program sent 72 employees to work with organizations in 19 countries. This evaluation was designed to assess program impact.

METHODS

The researchers administered a survey to 60 Fellows and 48 Pfizer Supervisors. In addition, the team conducted over 100 interviews with partner organization staff and other key informants during site visits in Uganda, Kenya, Ghana, South Africa and India, the five countries where 60% of Fellows were placed.

RESULTS

Over three-quarters of Fellowships appear to have imparted skills or enhanced operations of NGOs in HIV/AIDS and other health programs. Overall, 79% of Fellows reported meeting all or most technical assistance goals. Partner organization staff reported that the Fellows provided training to clinical and research personnel; strengthened laboratory, pharmacy, financial control, and human resource management systems; and helped expand Partner organization networks. Local staff also reported the Program changed their work habits and attitudes. The evaluation identified problems in defining goals of Fellowships and matching Organizations with Fellows. Capacity building success also appears related to size and sophistication of partner organization.

CONCLUSION

Public expectations have grown regarding the role corporations should play in improving health systems in developing countries. Corporate philanthropy programs based on "donations" of personnel can help build the organizational and human capacity of frontline agencies delivering health services. More attention is needed to measure and compare outcomes of international volunteering programs, and to identify appropriate strategies for expansion.

Public–private partnerships in blindness prevention: reaching beyond the eye

The control of river blindness (onchocerciasis) has been one of the major public health achievements of recent decades. Initially, vector control was used to stop transmission of the parasite Onchocerca volvulus by blackflies (Simulium) but the introduction of ivermectin (Mectizan) as a means of morbidity control enabled new strategies of distribution to be developed based on community directed treatment. The donation of Mectizan by Merck & Co. Inc. for onchocerciasis control in 1987 'as long as needed' was a public health landmark to be followed by a donation from GlaxoSmithKline of albendazole in 1997 for lymphatic filariasis to which Merck also responded by agreeing to extend their donation to include the coadministration of Mectizan and albendazole. Both the drugs, however, have wider impacts than those specific to filarial parasites and are effective against a range of intestinal parasites, whilst ivermectin has an important effect on ectoparasites. The wider benefits of the annual public health intervention-collateral benefits--therefore include deworming, improved nutritional status, increased growth, improved school performance and attendance, and improved haemoglobin status as a result of the impact of albendazole on hookworm, a major cause of anaemia. More recently, studies suggest that worm-free children have a significantly reduced frequency of malaria specific episodes of fever and Ascaris-infected children have a two-fold higher frequency of cerebral or severe malaria than those without Ascaris. These findings suggest that programmes based on annual interventions to control river blindness and lymphatic filariasis can contribute disproportionately more to a range of public health problems than has been hitherto recognized, thereby assisting in attaining the millennium development goal targets.

Ivermectin and onchocerciasis: is it all solved?

The donation of ivermectin by Merck and Co. Inc. has led to one of the most effective private-public partnerships controlling a disease of major public health importance particularly in Africa. The up scaling of ivermectin distribution during the last 15 years has been remarkable with almost 40 million people treated in 2003, many already on their regular annual dose. The tools that have been developed particularly by the APOC programme have been instrumental in this increase. However, ivermectin is a microfilaricide and does not kill the adult worms. Distribution will be needed for at least 25 years and latest estimates indicate that 90 million people need annual treatment if onchocerciasis is to be eliminated as a public health problem. In spite of this incredible progress it is difficult to see how the programme will be sustained, especially after the closure of APOC in 2010. A macrofilaricide destroying adult worms and safe for mass distribution would solve the problem of onchocerciasis.

The delivery of ivermectin (Mectizan)

Over a comparatively short period of time, the development and distribution of ivermectin (Mectizan) has radically altered the consequences of infection with Onchocerca volvulus. To achieve this required the fostering of many partnerships and the development of new tools and methods. The long-term commitment of Merck, the World Bank and other sponsors, as well as governments and non-governmental organizations, has been crucial. Yet the enthusiasm with which communities have taken up the delivery of ivermectin among themselves is perhaps the greatest reason for the success of this programme. The present challenge is sustaining the methods that have brought success so far, and making them part of health services and disease control programmes in some of the world's most impoverished and unstable areas. A major part of this challenge is continuing the commitment to controlling onchocerciasis as memory of the disease is fading, and while the hope of elimination or eradication for most endemic countries remains distant.