Making a public-private partnership work--an insider's view. Interview by John Maurice.

Interview Making a public–private partnership work — an insider’s view In November 1999, Dr Amadou Diarra was appointed senior director of Bristol-Myers Squibb’s Secure the Future initiative. Launched 18 months ago, this public–private partnership is seeking, together with the governments of nine African countries, innovative ways of reducing the transmission and the impact of HIV/AIDS, especially on women and children, through interventions involving medical care, research, community outreach, and education. Diarra, who was brought up in West Africa, had previously worked for about a decade with the company’s Africa division. Last November Bristol-Myers Squibb joined four other major pharmaceutical manufacturers and five intergovernmental agencies in supporting the UNAIDS initiative for Accelerating Access to HIV Care, Support and Treatment. Diarra played a significant role in laying the foundations for Bristol-Myers Squibb’s commitment to both of these public–private partnerships. He shares with John Maurice his views on what it takes to make a successful partnership of this kind. Q. What do you see as the key to a successful partnership in the health arena? A. First of all, we’re all of us — governments, international agencies, and industry officials — still on a learning curve with these relatively new partnerships. But we’re beginning to draw lessons from our early experience. Certain key elements are emerging. Q. Take them one by one. A. I’ll take the first two together — trust and flexibility. Without trust you just don’t have a partnership to start with. And without flexibility, the relation- ships on which your partnership rests can become very shaky. These two prerequisites are particularly crucial for Western firms working in Africa. An African health official once said to me: ‘‘You’re a private company and we’re a government, and we just don’t work in the same way. The US corporate culture your company works under is very different from our African culture. Without trust, open- ness, and flexibility we’re just not going to get very far.’’ Q. For your Secure the Future initia- tive you’re dealing essentially with individual governments, whereas for the UNAIDS Accelerating Access initiative you have to sit at the same table not only with international institutions but also with other pharmaceutical manu-facturers, with your competitors. A. There, too, you need trust and flexi- bility, but especially flexibility. Each company has its own philosophy, its own corporate agenda. Moreover, for reasons of competitivity pharmaceu- tical company officials do not discuss pricing among themselves. They do so only on a one-to-one basis with individual governments and custo- mers. So trust and flexibility are essential, plus a good dose of mutual respect. But it’s not always easy. Q. And with intergovernmental institu- tions, like WHO, UNAIDS, the World Bank, and so on? A. The big problem there is time. We in industry are used to getting things done yesterday. International institu- tions, with their specific constraints and multiple constituencies, can’t al- ways put the same value on time as we do. So, we mustn’t come to the negotiating table with fixed ideas and agendas. Flexibility is the key here. Q. Trust, flexibility, and ...? A. And persistence in the face of adver- sity. There are a lot of hurdles and you need a good dose of persistence to cross them. One hurdle that for-profit private-sector partners are particularly liable to encounter is public scepticism about motivations. Whenever we do something that contributes to human welfare but that is not motivated by profit, we tend to get negative com- ments. Q. Are you referring to press accusations that your Secure the Future initia- tive, which your chairman has called ‘‘the largest such corporate effort in history’’, was simply a response to mounting public pressure and an attempt to improve the corporate public image? A. Yes, there has been negative press about the initiative, and that criticism just didn’t take into account some basic facts. One fact is that we were offering our drugs to poor African countries at discounts of 30-40% back in the mid-1990s, when antiretrovirals were just appearing on the scene and when there was no public pressure to make them more widely available. We had even begun to help countries set up distribution systems to ensure access to these drugs. We had also worked through a Pan-African orga- nization to develop postgraduate training materials for doctors throughout the continent. Those are just some examples. But you need persistence to keep going in the face of public criticism or distrust over what you’re trying to achieve. Q. Was press criticism your only hurdle? A. Not at all. One of my biggest frustra- tions has been the lack of enthusiasm or encouragement that greeted our early offers of low-price drugs. I don’t believe medicines are the only way to tackle HIV/AIDS, but I think a Amadou Diarra C ha rlo tt e Ra ym on d/ Br is to l-M ye rs Sq ui bb 795Bulletin of the World Health Organization, 2001, 79 (8) # World Health Organization 2001 constructive dialogue with all the players in the field — activists, governments, agencies—would have been easier at that less emotionally charged period than it is today. And just as an example of how factors other than drug prices are involved, take Boehringer Ingelheim’s recent experience. This company announced in July last year that it would provide nevirapine (Viramunet) free of charge to developing countries for five years to prevent mother-to-child transmis- sion of HIV. To date, not more than seven of the 120 or so developing countries have taken up the offer. That company, which has also signed onto the Accelerating Access initiative, is going to need persistence for its donation programme to succeed. Q. Do you use ‘‘persistence’’ also in the sense of endurance? A. Yes, endurance, sustainability. All the partners must agree on how long they are expected to remain committed and the duration of the overall commitment must be set realistically. An example is the Merck Mectizant Donation Program, which was set up in 1987 to provide ivermectin for as long as it would be needed to bring river blindness, or onchocerciasis, under control. That’s a beautiful example of a public-private partnership, and look at the sustain- ability that was built into it right from the start! It’s still going strong nearly a decade-and-a-half later. Q. Trust, flexibility, persistence, endur- ance. Any other keys to a strong, dynamic partnership? A. Accountability. All the partners should know what the partnership as a whole is supposed to have achieved by such-and-such a time, what each partner is expected to do according to the agreed timeline, and what re- sources each has to put into the different steps needed to attain the intermediate goals and the ultimate goal. And you’re not only accountable to the public and the press, but also to yourself and your colleagues. If we decide to put, say, US$ 30 000 into a project, we have to consider how, five or ten years later, we will look back on that decision. Was it justified or not? Q. What about your accountability, as a for-profit company, to your share- holders?How do they take the loss in profits from your US$ 115 million donation to Secure the Future and from drug price cuts and your com- mitments to the UNAIDS Acceler- ating Access initiative? A. As a business we certainly have to consider the bottom line, namely profit. But as human beings, we’re pleased that the company is doing something concrete to fulfil its de- clared mission to enhance and extend people’s lives. And I have to tell you, the reactions of our first shareholders, namely our employees, have generally been very positive. You’d be amazed at the number of emails and phone- calls I get from our staff saying how happy they are at our commitment. Happy and proud. n Bristol-Myers Squibb’s Secure the Future initiative focuses on women and children with HIV/AIDS in nine African countries. This Swazi woman suffering from AIDS is holding her nephew, orphaned by the death of her sister, also from AIDS. C ha rlo tt e Ra ym on d/ Br is to l-M ye rs Sq ui bb 796 Bulletin of the World Health Organization, 2001, 79 (8) Interview