Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697632901149.pdf (Australia)
The role of the private sector in promoting economic growth and reducing poverty in the Indo-Pacific regionSubmission 151 Public-private partnerships in disease surveillance and health information systems.

• Although regretfully Australia’s Bangladesh bilateral programme is discontinuing support to icddr,b in 2015, the institution will continue to partner with the private sector to address the Indo-Pacific region’s most pressing health challenges with support from other donors.

Recommendations 1.
Recommendations 1.

DFAT should fund innovative models for engaging the private sector in public health and nutrition activities.
Key priorities include: • The role of private financing and private sector participation in health insurance in support of universal health coverage; • The role of the private sector in expanding access to quality child and maternal health services; • The role of pharmaceutical companies in product development partnerships for vaccines and drugs for diseases of poverty; • The role of microfinance in enabling women to improve their health status through economic and social empowerment.

2.
2.

DFAT should support public health research organizations located in developing countries to design, pilot and evaluate such interventions for scale-up in the Indo Pacific region.

3.

DFAT should support governments of Indo-Pacific countries to develop and implement coherent public-private partnership policy and financing frameworks in the health sector.
About icddr,b icddr,b is recognized by the donor community as a global centre of research excellence, carrying out and disseminating research relevant to its host country (Bangladesh) and the Indo- Pacific region.
It has served as a global centre of innovation for over 50 years, focused on maternal and child health, nutrition, vaccine sciences, emerging and re-emerging infectious diseases, health systems and universal health care, and the emerging threats of non- communicable diseases, urbanization and rising sea-levels.
icddr,b is now recognized as the world’s leading centre of public health and population research and training located in a developing country, and was the first recipient of the Gates Award for Global Health.

icddr,b has a strong track record in developing interventions that have significantly improved the health of women and children living in poverty, saving millions of lives worldwide.
In collaboration with academic and research institutions in Australia and throughout the world, the institution conducts research, training and programme-based activities to develop and share knowledge for global heath solutions.
icddr,b welcomes the opportunity to provide a submission to the Inquiry, which draws on Bangladesh case studies to address the following points of the Inquiry’s Terms of Reference: • The role of the private sector in accelerating the pace of economic growth and in reducing poverty in developing countries in the Indo-Pacific region.

• Current Australian Government support for private sector development through bilateral and multilateral investments.
• Additional partnerships, activities or financial instruments the Australian government could use to enhance the role of the private sector in development.

• The role of public-private partnerships in leveraging private sector investment in developing countries.

• Risks related to current and possible future approaches to enhancing the role of the private sector in development, and their management.
• The role Australian and international businesses could play to support development and inclusive growth in partner countries.

• The particular role of women in ensuring a thriving private sector.

2 The role of the private sector in promoting economic growth and reducing poverty in the Indo-Pacific regionSubmission 151 General observations icddr,b maintains that sustainable development requires a pluralist approach involving both public and private sector engagement.
The Bangladesh success story shows that a balanced approach is required that harnesses the strengths of the public and private sectors and mobilizes civil society for rapid social advancement.

Historically there was reticence among most public sector organisations to interact with the private sector to address health and development challenges for fear that such collaborations could be misconstrued as not being in the public interest.
However, the operating context has changed significantly in the last two decade and mind-sets are also changing.

It has become increasingly realised that the private sector can contribute a tremendous amount to health responses in terms of skill sets and financial resources.
Further, relatively new global health players such as the Bill and Melinda Gates Foundation and the Global Alliance for Vaccines and Immunisation (GAVI) explicitly encourage public-private collaborations and provide considerable resources to do so.

Financing provided by foundations and governments can be key to public-private partnerships, making it a clear win-win for both sides.

Socio–economic and attitudinal changes (e.g.


in relation to the status of women) are also driving fresh thinking and a willingness to work across sectors.

icddr,b has long focused on women’s empowerment as a key challenge in our holistic approach to development and we recognize that women play an essential role in ensuring a thriving private sector.
It is encouraging to see that there are now scores of examples of women engaged in leadership roles in small-to-medium scale entrepreneurship all over Bangladesh.

The growing role of women in the private sector is key to the future equitable development of the society as a whole and contributes to the health and welfare of families and communities.

Bangladesh has made remarkable progress in health and development in recent decades.
Successes in expanding the coverage of immunisation, mass mobilisation to combat childhood diarrhoea, and advances in tuberculosis control indicate the importance of public health interventions to development.

National scale up of family planning programmes has supported a dramatic decline in the total fertility rate.

Microcredit programs for poor women and scale-up of universal education have strengthened the foundations for good health.

In all of these areas the private sector has played a role.
The pluralistic nature of the health sector has supported this remarkable progress.

The multiplicity of stakeholders engaged in the Bangladesh health sector has generated positive outcomes because of a dynamic combination of forces ranging from the legacy of traditional care systems to the enterprise of the private sector and a permissive public sector.
1 The urban health sector in Bangladesh is increasingly dominated by the private sector, which plays an essential role given that the public sector cannot meet escalating demand for services.

Private pharmacies are major health care providers for households, accounting for nearly two thirds of out-of-pocket spending.

There are more private hospitals than public hospitals.

The challenges however are in terms of equity (who can afford private sector services) and quality assurance.
Bangladesh was the first low-income country to develop a local pharmaceutical industry, which currently accounts for 75% of domestic market share.

While rapid expansion of availability of cheap generic pharmaceuticals has increased access to essential drugs, it has also highlighted the essential role of the public sector in addressing issues such as counterfeit drugs, overprescribing and sub-standard manufacturing practices.
Regretfully, lack of effective 1 Syed Masud Ahmed, Timothy G Evans, Hilary Standing, Simeen Mahmud, (2013) ‘Harnessing pluralism for better health in Bangladesh’, The Lancet, Vol.

382, Issue 9906, 1746-1755.

3 The role of the private sector in promoting economic growth and reducing poverty in the Indo-Pacific regionSubmission 151 regulation results in unnecessary and even harmful drugs often dispensed without a prescription, and in less than required dosages leading to the development of drug resistance.
icddr,b plays a role in ensuring quality and accessibility and contributes by conducting research in the areas of accountability, governance and equity (e.g.

through the institution’s Centre for Equity and Health Systems) to ensure the mix of public and private services supports Bangladesh to achieve its health goals.
For example, icddr,b engages in dialogue with government partners on regulatory approaches, conducts research on how to improve the quality of services provided by private providers, and provides certification and training schemes for selected private health services.

The private health sector has been key to recent advances in reaching national health targets and will play a pivotal role in ensuring progress towards universal health coverage.
icddr,b contributed to and endorses the Government of Bangladesh’s Health Care Financing Strategy 2012-2032, which aims to maximize the complementary role of the private sector through contracting and public private partnerships to achieve universal health coverage by 2032.

The centrality of the private sector is demonstrated in pharmaceutical product development.
In developing countries such as Bangladesh, the private pharmaceutical sector is an obvious partner for public sector agencies seeking to address increasing demand for medicines and other pharmaceutical needs, and is essential to bring products to scale.

There is a burgeoning pharmaceutical industry in Bangladesh that presents agencies such as icddr,b with many potentially suitable partners for product development.
icddr,b focuses efforts on local private sector manufacturers seeking to provide pharmaceutical supplies to public sector programmes.

icddr,b also partners with the major international pharmaceutical companies in development of new vaccines and therapeutics (e.g.

GSK, Merck, Pfizer).

Health programmes can benefit significantly from the public sector providing financial incentives that enable the private sector to participate in public health initiatives.
For example, the Global Alliance for Vaccines and Immunisation (GAVI) and the financial instruments used by GAVI that have successfully brought down prices for new vaccines for developing countries to levels that never would have been anticipated.
Partnerships with the vaccine industry are an integral part of GAVI’s business model and it has developed new financing mechanisms such as the International Finance Facility for Immunisation, which engages the finance industry to mobilize resources required to sustain funding for immunisation.

GAVI support has enabled Bangladesh to dramatically increase the number of immunized children since 2000.
Bangladesh is on track to achieve the Millennium Development Goal targets for reducing maternal mortality levels from 1990 to 2015.

The drop in maternal mortality has mainly arisen due to improved access to and use of health facilities, a large and increasing proportion of which are provided by the private sector.
Additionally, a number of favourable changes occurred during this period: fertility decreased; income per head increased sharply and the poverty rate fell; and the education levels of women of improved substantially.

A rapid increase in the availability of, and access to, private sector facilities after 2001 contributed to the increased use of health facilities.

Both availability and access to facilities offering delivery services improved substantially during the past decade.
The number of public sector facilities offering services to women showed almost no increase from 2001 to 2008.

Private facilities more than doubled, and private facilities represent over 80% of Comprehensive Emergency Obstetric Care facilities.2 2 See: Shams El Arifeen, Hill K., Ahsan K. Z., et al.

(2014) Maternal mortality in Bangladesh: a Countdown to 2015 country case study, Lancet 384: 1366–74 .
4 The role of the private sector in promoting economic growth and reducing poverty in the Indo-Pacific regionSubmission 151 Challenges While an expanded private sector role is essential to underpinning effective responses to many of the key health challenges facing developing countries, significant challenges remain for consideration by governments and donors.
The private sector is understandably concerned primarily with its financial and commercial interests and obtaining a return on share holder investment.

At times this can conflict with important public health objectives.

In the past, issues have arisen that have brought industry into direct conflict with public health authorities (e.g.

the baby milk scandal surrounding infant milk formula products).
Currently we are faced with a range of complex issues regarding the responsibilities of the private sector in public health (e.g.

the role of tobacco companies in relation to cancer, and the food and beverage industry in addressing non-communicable diseases such as diabetes and heart disease).

There remains a high degree of sensitivity to involvement of the private sector in nutrition due to a history of unregulated commercialization and disregard for norms of child growth and nutrition.
Clearly there is a role for regulation however the nature and extent of that regulation is a matter of contention.

It is abundantly clear however that the way forward involves the public sector working with the private sector to confront public health challenges and resolve issues, rather than these sectors working in isolation.
It should also be emphasized that an increased focus on private sector roles should not detract from the need for donors to continue to support governments, research organizations and NGOs in responding to extreme forms of human poverty.

The non-profit sector and government safety nets will remain key to addressing the consequences of extreme poverty.
Case studies: private sector engagement in health initiatives in Bangladesh 1 Zinc supplements icddr,b was one of the first organisations to demonstrate the benefits of zinc treatment in diarrhoeal disease as a life-saving therapy.

The Scaling Up Zinc for Young Children (SUZY) Project commenced in Bangladesh in 2003 and was one of the first national efforts conducted anywhere in the world to expand zinc treatment coverage for childhood diarrhoea.
icddr,b showed that zinc supplementation during diarrhoeal disease has multiple benefits, and this evidence informed global guidelines on treatment of diarrhoeal disease.

The strength of icddr,b’s evidence led WHO and UNICEF to launch revised global guidelines recommending zinc supplementation for children under five years of age.

At country level, the private sector played a central role in the SUZY project.
Consultations with carers revealed that private sector suppliers were overwhelmingly the first access point for families.

icddr,b found that 90% of healthcare provider visits for childhood diarrhoea were to private providers.

This led to an early, strong emphasis on the private sector in distribution efforts and scale-up has been based on private sector infrastructure e.g.

private pharmacies.
private pharmacies.

icddr,b purchased patent rights from the French company Nutriset to enable a Bangladeshi pharmaceutical laboratory to manufacture and distribute a zinc formulation that can be dissolved in water.

ACME Laboratories Ltd, a local pharmaceutical manufacturer, were awarded a contract to distribute the zinc tablets, marketed under the name ‘Baby Zinc.’ In addition, a local communications agency was engaged on a publicity campaign to raise awareness and promote product use.
The campaign achieved some notable successes, particularly in raising awareness of zinc treatment.

From very low starting levels, awareness reached 65 per cent in poor urban areas and 55 per cent in rural areas.

Actual use was not so high.


Nevertheless, within 18 months about 30 per cent of urban non-slum households and 20 per cent of households in urban slums were using zinc therapy; uptake was lower, 10 per cent, in 5 The role of the private sector in promoting economic growth and reducing poverty in the Indo-Pacific regionSubmission 151 2 3 rural areas.

Importantly, the campaign appeared to have no detrimental impact on the use of oral rehydration therapy, the first-line treatment for diarrhoea.
Encouragingly, recent national surveys indicate that nearly 40 per cent of diarrheal episodes in under- five children are now treated with zinc.

Cholera vaccine The transfer of vaccine technologies to the private sector helps improve public health.

Our experience in the vaccine field is that a key challenge faced is identifying a private sector partner willing to take the financial risk.
Working with the private sector is also a sensitive public reputational issue, which is managed by involving international bodies such as the World Health Organization and GAVI as well as government partners.

Private sector partnerships have proven key to development of a low cost, high-impact oral cholera vaccine.
A joint project between icddr,b, Incepta Vaccine Limited and international partners is expediting the development of a next-generation oral cholera is working with Hilleman vaccine for use Laboratories, Merck & Co., Wellcome Trust and Incepta Vaccine Limited to fast-track clinical trials, product licensing and commercialisation of the high-impact oral vaccine.
Incepta Vaccine Limited is a vaccine research and manufacturing company based in Bangladesh, and provided support in process development, scale-up and manufacturing of the vaccine for pre-clinical and clinical studies.

low-income countries.

icddr,b in Hilleman Laboratories, based in India, is a non-profit research organisation focused on the development of vaccines for low-income countries.
It entered a joint venture partnership between Merck & Co., a global pharmaceutical company and the Wellcome Trust, a global charitable foundation.

Hilleman Laboratories is contributing its expertise to the process, formulation and pre-clinical development of the vaccine.

This collaboration is allowing not-profit and private sector organisations to work together to accelerate the development a cheap effective cholera vaccine for the developing world.
TB screening Strengthening of public private partnerships in TB control is essential to increase the accessibility to care, to improve the quality of diagnostics in the private sector and for overall improvement of TB management as part of the national TB control strategy.

A new icddr,b project launched in 2013 is implementing a social enterprise model for strengthening TB control in Bangladesh through involvement of the private sector.
icddr,b established a network of physicians in the private sector to improve patient access to TB services.

Three TB Screening Centres were established across Dhaka and provided with TB diagnostic equipment including the Delft X-ray system, GeneXpert systems and the Spirometry and Blood Glucose Monitoring system.

A large donation of GeneXpert machines was a key factor.

The Screening Centre sites were selected for maximum geographical coverage and accessibility to patients.
Patients are interviewed by Community Screeners using an Android smart phone-based dedicated application to identify TB suspects.

These patients are then referred by the physician to the nearest icddr,b TB centre for low-cost, high-quality digital chest X-ray.

A communication strategy has been developed by icddr,b to promote the project activities among local stakeholders and to the physicians, including posters for pharmacies and clinics, brochures, calendars and referral pads.
In the first three months of the project, over 25,000 individuals were screened for TB symptoms and over 250 new TB cases were detected.
6 The role of the private sector in promoting economic growth and reducing poverty in the Indo-Pacific regionSubmission 151 4 5 to meet Microcredit programmes for rural women Microcredit schemes are a form of microfinance that makes small loans available to poor people, especially those traditionally excluded from financial services, through programmes designed their particular needs and circumstances.
The effectiveness of microcredit programs in empowering women in Bangladesh has been documented by icddr,b over several decades.

Recently, a joint research project evaluated the extent to which socioeconomic development through these microcredit enhances maternal and child health outcomes.3 The review showed promising positive linkages between implementation of microcredit programmes in rural areas and increase in income, increase in health status and improvement in women’s health.
Data from several studies indicates that increasing women’s empowerment through income and education leads to improvements in health and survival.

The recent review also found that microcredit may have some unintended negative effects on health e.g.

the health status of young children.


Women’s participation in employment and other activities may involve leaving the supervision of small children to other caretakers less able to respond to their particular health needs, such as for breast-feeding or the preparation of energy dense weaning foods.

Therefore, interventions tackling women’s empowerment also need to focus on ‘collective empowerment’ and not just individual needs.
This can be accomplished through a number of low-cost methods such as the establishment of community centres or providing loans to women to establish low cost day care for other women.
Other challenges identified include: loan control and misuse by male members of households, increased workloads and responsibilities, and financial sustainability over time; criticism that the programmes have difficulty reaching the most vulnerable populations whether related to choice or exclusion; apprehension about the gender and power relations and the cultural constraints placed on women, which can lead to poor outcomes; and the association between health decline and business failure.
Further research is required to help guide development of microcredit programmes to effectively empower women in rural contexts.

Family planning icddr,b pioneered family planning programmes in Bangladesh in the 1970 and 1980s.

In recent years, both the public and private sectors have expanded their roles in the growing family planning market in Bangladesh.

This expansion has improved the efficiency of the National Family Planning Programme.
An effective public–private model has evolved for serving the contraceptive needs of the country.

The private sector (private providers/clinics, commercial pharmacies, social marketing companies and nongovernmental organizations) has for contraceptives by becoming a major partner of the public sector in the contraceptive market.
Clients who are wealthy and can afford to buy contraceptives access the private sector, freeing up resources enabling the public sector to better reach poor and underserved populations.

the growing demand responded to Bangladesh has been highly effective in scaling up family planning programmes through social marketing approaches that apply commercial marketing tools and concepts to influence behaviors that benefit communities.
The Social Marketing 3 The Case for Microcredit: Does It Improve Maternal and Child Health and Wellbeing?

International Journal of Public Health Science (IJPHS) Vol.3, No.2, June 2014, pp.

107~116 7 The role of the private sector in promoting economic growth and reducing poverty in the Indo-Pacific regionSubmission 151 in family planning globally.
SMC partners with Company (SMC) is one of the largest and most successful private sector social marketing organizations the Government of Bangladesh in the national Family Planning Programme through marketing of products at affordable prices and wide scale distribution.
SMC’s core operation is non-profit in nature but it also operates for-profit manufacturing and trading activities that generate a financial surplus, which is utilized to stimulate business growth, broaden access to product and improve quality of products and services offered by the company.

6 Oral rehydration solution4 Researchers at icddr,b invented oral rehydration solution (ORS) for use in the treatment of cholera and other diarrhoeal diseases.
ORS is now used globally and is credited with saving over 50 million children’s lives to date.

Reducing deaths from diarrhoea has helped Bangladesh become one of only eight countries to have reduced mortality rates of children under five by at least two-thirds since 1990, in accordance with the Millennium Development Goals.

Since 1990, the Bangladesh-based Social Marketing Company (SMC) has played a key role in ORS distribution.
SMC’s marketing campaigns have focused on mothers, supported by empowerment initiatives for women such as education and microfinance.

ORS marketing included a range of media such as radio, TV, cinema, billboards, wall paintings, neon signs, mobile film units that served rural areas, point-of-purchase advertisements (dispensers, posters, stickers), printed materials for providers and consumers, poem books for rural readers with SMC ads, and product logos on transport.
SMC’s marketing and distribution has contributed to successful national scale up of ORS.

ORS was sold from 220,000 retail outlets serviced by twelve sales offices around the country.

To become self-sufficient, SMC built a manufacturing facility in 2004 and a central warehouse in 2008.

In 2011, SMC sold roughly 300 million sachets, up from 16 million in 1992.

Their packages are now found in local grocery stores and pharmacies.
SMC has welcomed the recent entry of other ORS manufacturers as the overall market has grown.

The sustained success in the scale-up of ORS can be attributed to the privatization of the manufacturing and distribution of ORS.

SMC has become self-reliant by developing the manufacturing capabilities in Bangladesh and building relationships with retailers and pharmacies.
Although government health providers issue ORS to patients for free, the vast majority of patients choose to pay a nominal price through private providers due to easier access.

7 Community health insurance Out-of-pocket healthcare costs force over five million people in Bangladesh back into poverty every year.

Bangladesh requires insurance schemes for pooling health risk that use commercial design for long-term sustainability.
icddr,b has conducted a rural pilot study that has demonstrated an effective model that reduces out-of-pocket healthcare costs and supports universal health coverage at village level.5 The pilot established a community based insurance scheme by which villagers pool their money by using the concept of risk protection as an incentive for prepayment of health care costs through premiums.
A model for prepayment of healthcare cost was developed, based on an assessment of the healthcare needs of the population on the basis of actual burden of disease and cost of services provided by various for-profit and 4 University Of Washington Global Health Start Program (2012) Bangladesh ORS Case Study.

5 icddr,b, Recent learning from a community health insurance scheme in Chakaria, Bangladesh, Research brief 2013.
8 The role of the private sector in promoting economic growth and reducing poverty in the Indo-Pacific regionSubmission 151 not-for-profit organisations.

The pilot required formation of a network of hospitals, drugstores, and diagnostic centres and development of a computer-based real-time information system.

Under the scheme, initial consultations for patients are provided at the community level in the Village Health Post.

Any cases needing further care are referred to a private hospital.
A memorandum of understanding between icddr,b and the private hospital was signed to ensure quality of care and re-imbursement by icddr,b when invoices are sent by the hospital to icddr,b.

Patients do not need to pay the hospital as long as the cost is within the entitlement of the patients defined by the scheme.

The hospital is informed of the maximum amount that can be paid by the scheme to the hospital.
Memoranda of understanding were also signed with 23 drugstores to supply medicines to the scheme members.

This newly-formed network of healthcare providers is connected through a computer- based management information system.

This database and patient-record system enable capturing of real-time data and maintenance of clinical records for members of the scheme.
The scheme ensures that no cash payment by patients is necessary at the point of service, and members enjoy a discount for drugs from the designated pharmacies.

The hospitals, diagnostic laboratories and drugstores submit bills to the icddr,b project office for reimbursement.

Food products to address severe malnutrition.

icddr,b has pioneered the development of ready to use therapeutic food to address severe acute malnutrition in children.
Olympic Industries, a food processing company and the largest biscuit manufacturer in Bangladesh, manufactures ready-to-use supplementary food using a recipe developed at icddr,b.

The supplementary food product has been used in a trial among 5,000 children of poor and food insecure households in rural Bangladesh.

Disease surveillance and health information systems Health information plays a critical role in informing efficient investments in health systems.
icddr,b has included private hospitals in a national disease surveillance networks so that data from private health care providers is reported to national health authorities as part of surveillance efforts.

To extend this work, icddr,b has proposed that the Government of Bangladesh introduce a common electronic health information system for both public and private health care providers so that more accurate and comprehensive information can be collected.
8 9 Conclusion icddr,b is grateful to the Government of Australia, which has been supported our work since 1978 and has been a highly valued partner.

Australian aid funding, which we have recently been advised will be discontinued in June 2015, has helped enable icddr,b to remain at the forefront of public health and medical research focusing on developing countries.

From July 2015, icddr,b’s core donors will be Bangladesh, Canada, Sweden and the UK.
DFAT’s increased focus on the role of the private sector under its new aid paradigm offers new opportunities for the Australian Government to strengthen its role in the health sector to support the goal of poverty reduction in the Indo-Pacific region.

9 The role of the private sector in promoting economic growth and reducing poverty in the Indo-Pacific regionSubmission 151 The role of the private sector in promoting economic growth and reducing poverty in the Indo-Pacific regionSubmission 151