Not all PNA effort is about benefiting the originating institution and many of the most successful global partnerships develop a series of wider missions geared towards educational, social or economic goals. Three particular types stand out: international partnerships, commercial partnerships and models without government.
KPMG analyzed 53 educational collaborations between health service providers from different jurisdictions to look for trends and key features of success.
For the most part, these are institutions from high-income countries, most notably the US, assisting underdeveloped or emerging health systems. Some of these partnerships date back as far as the 1970s and 1980s.
Many of these partnerships are done on a charitable basis, while others are revenue neutral or even revenue generating for the originating institution. Governments are often a key player, as with the partnership between National University of Singapore (NUS) and Duke University in North Carolina. Work commissioned by NUS identified that it needed to develop a postgraduate medical course, particularly if it wanted to develop the physician-scientist role. Thus equipped, it could strengthen its contribution to the Singaporean economy and to the quality of clinical services at the National University Hospital. It identified Duke’s MD/ PhD program as highly relevant. An agreement was reached in 2005, for Duke to support the postgraduate program with US$100 million over 10 years. Similarly, the Ministry of Health in Kuwait in 2010, went out to the North American market looking for a partner to secure sustainability for the Comprehensive Cancer Centre in Kuwait City. Without such a partner, its workforce would lack experience (and probably interest) to deliver services locally and thus the tendency for Kuwaiti citizens to travel for treatment would continue.
The Ministry selected and contracted with the UHN in Toronto. Contributory to the decision was a view that the UHN would be more likely than institutions with pre-conceived educational packages to adapt to the cultural requirements of Kuwait (for instance, email is not a preferred form of communication compared to text messaging or formal communications).
These partnerships can be highly effective at developing the soft infrastructure of a strong health system and often create two-way learning (or reverse innovation) for the originating organization. Not all partnerships are simple one-to-one arrangements. KPMG is currently engaged in identifying multiple international academic partners to assist an Indian client with ambitions to grow from an acute hospital into a major academic health sciences provider. Nilaya Varma, Head of Health, KPMG in India, notes, “Our client is clear, for the development of a major health sciences mission, a number of partners are required. That gives us the challenge of sourcing the partners and also creating a commercial and governance structure which works for all the partners and the client’s overall mission.”
The role of health organizations as economic generators is increasingly well understood. Governments in Australia, Canada, the UK and US are seeking to develop strategies to maximize the economic return of their major healthcare institutions.
One popular form of economic partnership is between health services and the life sciences industry. Our research indicates two developing trends: first, for life sciences to forge stronger alliances with universities; and secondly, for these alliances to be concentrated in fewer institutions. The most prominent of these is the decision by Astrazeneca to invest close to US$600 million in and transfer approximately 1,000 staff to the Cambridge University Hospital. Smaller and equally significant partnerships include, Sanofi with the University of California, San Francisco; Johnson and Johnson with the University of Queensland; Novo Nordisk with Oxford University.
Relevant to the success of these partnerships is academic pre-eminence. What is also striking are the number of developments aiming to consolidate a range of partners in a single location. Examples include, the longstanding plans at Charite in Berlin, Parkville Precinct in Melbourne and Liverpool in the UK.
For Aidan Kehoe, CEO of the Royal Liverpool and Broadgreen NHSTrust, this raises interesting challenges of working with and evaluating the capability of academic and commercial partners. He places high value on the personal relationships between the key leaders and notes how particularly important this has been for his work with Liverpool University. The relationship permits candor which in turn enables realism about the partnership. It also helps the management of potentially conflicting or ambiguous objectives.
Other partnerships operate as part of health science-related economic zones. The University of Maastricht, embedded in the most economically productive region of the Netherlands, with its associated university hospital, was launched in 1976.
It is closely linked to the Brainport Eindhoven technology initiative and neighbor to a range of health technology companies such as Medtronic and Phillips. Its services and science are closely aligned to these industries with a focus on cardiovascular disease and neurosciences.
When it comes to wider social contribution models, those countries with either Bismarck or Beveridge based health systems, or the US aiming to increase the insured population, would say they are underwriting or increasing the social relevance of health services. But what is interesting within some countries is where the healthcare model works successfully without articulation by the state. In India, Apollo Hospitals has for some time worked on extending reach from primary through to tertiary care in many cities. In recent years it has become a payer as well as a provider. The intention is to increase access to services through low cost health plans. By doing this, it effectively creates a health system independent of the state.
Successful models for low-cost healthcare, independent of the state, are even more striking in Africa. Here, organizations such as PharmAccess, have created models of usage for grants and private equity funds to secure health insurance cover for 110,000 people across three sub- Saharan African countries.
Investments in specific donor programs, e.g. for HIV, malaria, tuberculosis, are structured through risk equalization mechanisms to pool risk more effectively. This in turn encourages investment into the health supply chain and the introduction of technology and services based on the size of the insured populations to create scale and thus a return.
Dr Onno Schellekens, Managing Director of PharmAccess, states that private equity is demonstrably superior to the state in the development of access to, and delivery of health services in Africa. “These schemes initially offered solidarity based on disease risk while enabling the development of an efficient private supply chain through insurer-provider contracts, which allowed the willingness to pay for healthcare to increase. As a result, a shift took place from systems with a large share of expenditure financed out of pocket towards systems with a high risk pooling and prepayment element.”