1. Slide 1 Win-Win or Lose-Lose? Why is multi-stakeholder involvement essential? Saul Walker Senior Health Advisor UK Department for International Development

2. 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

3. 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?

4. Expanding Equitable Access Available to the poor Keeping Costs Affordable To patient and to the health system Effective interventions Levels of care, innovation 4 Competing Pharmaceutical Policy Objectives? Adapted from: Dennis Ross-Degnan (HMS) Political cycles Economic policies External drivers Organisational politics

5. Slide 5 taxes ConsumersProviders payments treatment Government (MOH) information standards, payments Drug Industry standards lobbying $$ marketing promotion oversight Consumer Organizations lobbying support information standards, education Professional Organizations lobbying 3rd Party Payers payments payments, controls coverageprice information Adapted from WHO

6. 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

7. Donors Domestic political concerns Regulations Foreign/industrial policy Pharmaceutical companies Profit focus (short/long) - marketing Opportunity costs Intellectual property Strategies for market share/volume Wholesales, distributors, retailers Profit focus (short/long) Opportunity costs Strategies for market share/volume International Agencies Profile/funding Overlapping agendas Organisational structures/politics Political outlook Country Governments Low budget allocation Competing objectives Vested interests Political outlook People/Civil society Overconsumption/self medication Poor adherence Disease specific groups Funding/profile etc Belief systems Potential for Poor Health Outcomes

8. 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

9. 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

10. Pharmaceutical companies Accurate information on pricing Proactive role Better procurement and forecasting Achieve public health objectives Reduce pressure for inappropriate behaviour Wholesales, distributors, retailers New support for building capacity Improved market operation Tackle corruption & wasteful practices Donors Good governance agenda Increase access to medicines Support responsible business Increase aid effectiveness International Agencies Good governance agenda Promote ethical pharmaceutical procurement and supply Improve health outcomes Country Governments Demonstrates commitment to good governance – ↑ donor confidence Improved procurement and supply Better public health outcomes Civil Society Increased information Place at the table Supportive environment for advocacy Financial and other support Improved dialogue with public and private sectors Alignment on Transparency

11. 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)www.medicinestransparency.org/meta-countries

12. 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

13. 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)

14. 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

15. 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

16. Slide 16 Leading the UK government’s fight against world poverty Tel: +44 (0) 20 7023 0000 Fax: +44 (0) 20 7023 0016 Website: www.dfid.gov.uk E-mail: enquiry@dfid.gov.uk Public Enquiry Point: 0845 300 4100 If calling from abroad: +44 1355 84 3132 LONDON 1 Palace Street London SW1E 5HE EAST KILBRIDE Abercrombie House Eaglesham Road East Kilbride Glasgow G75 8EA