Q&A: UNITAID chief goes behind the scenes on new five-year strategy

MAPUTO, Mozambique — Global health partners met in Mozambique earlier this month to discuss how to leverage innovation in the fights against HIV/AIDS, tuberculosis, and malaria. At a forum organized by Mozambique’s Ministry of Health and UNITAID — with the participation of partners including the U.S. Agency for International Development, UNAIDS, UNICEF, Jhpiego and the Clinton Health Access Initiative — officials discussed key challenges, such as development and delivery at scale of health innovations, the creation of sustainable markets, and the role of partnerships.

All of these issues are particularly paramount to UNITAID, which invests in new ways to prevent, diagnose, and treat the three pandemics. Founded by Brazil, Chile, France, Norway and the U.K., the agency aims to fill the gap between the late-stage development of health products and their widespread adoption through funding by governments and major donors, such as the Global Fund and PEPFAR, the U.S. President’s Emergency Plan for AIDS Relief.

UNITAID was created in the height of the battle against HIV/AIDS, tuberculosis, and malaria, but its new strategy focuses on a more integrated approach to health — a trend initiated with the Sustainable Development Goals. Devex caught up with Executive Director Lelio Marmora on the sidelines of UNITAID’s Partners Forum in Mozambique to learn about its strategies to mobilize resources, shape health markets, and manage risk through a finely honed multi-partnership approach. Our conversation has been edited for length and clarity.

Shaping health markets and the innovation agenda is central to the work of UNITAID. What are your strategies for influencing pharmaceutical companies to invest in a new drug or diagnostic test?

We [serve as a link] between R&D and implementers. First of all, we identify gaps in health responses alongside the products that should be developed or improved to fill them. The innovation value chain is riddled with barriers, so our projects are geared toward solving the various scientific, commercial, legal, and logistical bottlenecks. Through large-scale pilots, we demonstrate the effectivity and feasibility of a particular innovation, while creating demand among key providers and end users.

At this point, offers start to surface: labs can bring down prices; other companies may enter the market, spurring a very healthy competition; and generic drug manufacturers may also come into play as intellectual property rights are granted in low-income countries.

Labs respond to profitable, sustainable markets. Hence, we partner with major donors to fund scale-up and a sustained global demand, and we also engage civil society, which puts pressure on national authorities to accelerate the uptake of new drugs. This multi-partnership approach to development is as fascinating as it is complex: it must be undertaken with the utmost precision, blending technical and political elements.

UNITAID leverages market intelligence and partnerships to drive innovation in global health. What has been the response of the private sector so far?

There are lots of myths about the private sector, [including] claims to the effect that it is very difficult to work with it, that it only cares about money. We honestly think this is not true. You would be surprised about how socially conscious labs are and about their many commitments to social good. There is a lot we can achieve by working with the private sector, making the most of its strength in terms of innovation, while making it work in a functional way for the common good.

The UNITAID strategy for 2017-2021 stresses the need to further increase effectiveness and mobilize resources. What strategies do you rely on to achieve these objectives, especially in a tight budgetary environment?

We have a three-pronged approach. For starters, international development has undergone a hyperspecialization. This means that, to remain strong players, we must deliver specific results and a return on investment just as a private fund would.

A second pillar is our connection to other major actors in this sector. Unfortunately, working in silos is still quite common. Ego is the great ailment of our times, and I continually remind my teams to keep it on check. I encourage them to be open, generous, and intellectually flexible, because great things in life are accomplished through teamwork.

A third element is maintaining a very systematic and smart approach to raising public and private funds, including through new financial mechanisms. By combining these three approaches, we aim to convince donors that supporting UNITAID is a good choice that will maximize their investment in other sectors.

UNITAID obtains about 60 percent of its resources through an airline ticket levy. Beyond this mechanism, which innovative financial instruments is UNITAID exploring? And when will it start implementing them?

Blended funding is a very attractive mechanism. Countries could borrow money from development banks and international aid agencies, and UNITAID could step in to cover interest rates and administrative expenses. We are discussing this option with development banks, the Spanish Agency for International Development Cooperation (AECID) and the French Development Agency (AFD).

Such a mechanism is well-suited to one-off programs that tackle very specific problems. For example, a country may need a certain amount of resources to eliminate hepatitis C, a curable disease that does not require lifelong treatment. This investment would be an ideal candidate for a blending operation.

In terms of timing, we will launch these types of operations as soon as the opportunity presents itself: we must know what we want, but we must also be opportunistic in the sense of doing what is possible at each moment in time.

From your perspective, how critical are national contributions by recipient countries and why?

National contributions are key. Developing countries can no longer depend on the international community for various reasons: sovereignty, freedom to choose their own strategies and, above all, sustainability — the frailty caused by dependence conspires against development. This is why UNITAID, alongside all global health agencies, greatly stresses national contributions. Many countries have already understood that health must be one of their top priorities and great progress has been made as a result.

A key component of UNITAID’s new strategy is a more integrated approach to health, especially in reproductive, maternal, newborn, and child health. How will this priority be reflected in upcoming calls for proposals?

The long-dated debate on verticality versus horizontality or integration in the response to pandemics does not make much sense to me. At the turn of this century, the global community created vertical funds to curb the 8 million annual deaths caused by HIV, malaria, and tuberculosis. This was very effective, but things have changed, and we must now embrace a more holistic approach to global health. Therefore, UNITAID will put forward integration systems that are effective, as well as economically feasible and institutionally sustainable.

Our calls will increasingly focus on patients, rather than on a specific disease. A couple of examples: we will call for proposals on child fever management — fever may be caused by illnesses ranging from malaria and zika to cholera — and we will support multiplatform diagnostics for diseases such as HIV/AIDS, hepatitis C, hepatic tuberculosis, or sexually transmitted diseases. We will also invest strongly in the fight against antimicrobial resistance, which is already embedded in over 50 percent of our portfolio.

In terms of implementers, we will look for partners that understand these evolutions in global health and development.

What role will South-South innovation transfer play in upcoming projects?

Intelligence, talent, and quality are uniformly distributed worldwide, but information is not. For this reason, a good deal of our projects encourage South-South knowledge transfer. As we are speaking, we are kicking off a project of Pre-exposure prophylaxis (PrEP) for HIV in Brazil, which will be formally launched this November. This initiative will surely give us plenty of material to set up lines of South-South cooperation.

UNITAID strives for measurable impact, scalability, and value for money. What does its approach to risk-taking look like, and what is your vision for UNITAID through 2021?

Taking risks is crucial in international development. If one plays it safe, gains are smaller, so there is a very interesting — and sometimes fun — tension when weighing up risks against potential results. Fortunately, our board allow us to take calculated risks, and our portfolio keeps a balance between bolder and safer operations. We commit mistakes, but we identify them quickly and adapt our projects accordingly.

I always urge my teams to prioritize action. It is better to make 10 and get three wrong, then take corrective measures and move on, than to make only three while striving for perfection. In the next five years, UNITAID should further consolidate itself as a relevant, groundbreaking innovation agent, avoiding individualism and trying to be as useful as possible to the global health response. 

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