Does MSF need a more intelligent/empathetic approach to partnerships?

Co-authors: Louis Potter 1, Ian Gray 2, Pete Masters 3.

Contributors/Panellists: Eimhin Ansbro 4, Alwena Hall 5, Darin Zehrung 6, Kathy Kalafatides 7

1 MSF Sweden Innovation Unit, 2 Gray Dot Catalyst / Partnership Brokers Association, 3 MSF UK, 4 London School of Hygiene and Tropical Medicine, 5 Philips Healthcare, 6 PATH, 7 MSF Canada

This position paper is a result of a break-out session that took place at the MSF Scientific Days in London in May 2018. The session consisted of a discussion and debate style format drawing on the experience of a purposively selected group, including a chairperson and four panellists (all contributors to this paper), MSF staff, representatives from partner organisations and subject matter experts. The question posed during the session was: Does MSF need a more intelligent/empathetic approach to partnerships? This paper attempts to draw together the main themes and perspectives in order to stimulate a reflective conversation about how MSF approaches partnerships in its innovation work.

Position - The need for pragmatic partnerships

If MSF is to achieve maximum value from its investments in innovation for frontline staff, patients and the communities they live in, partnerships need to play a key role. Currently, our discomfort with forming partnerships — particularly with the private sector — hampers our ability to deliver patient-centred care to the best of our ability. In this article, we argue that a pragmatic and intelligent approach should be one of MSF’s key principles when identifying, exploring and agreeing external partnerships.

Patient-centred, not MSF-centred

‘Not our core business’ is a not-uncommon refrain in MSF when discussing innovative ideas, our innovation process and how we should invest our resources. Sometimes it is true – not every initiative should be resourced and we should focus on those that will have a tangible impact on our work and the care we provide. However, all too often this statement goes unchallenged. Is it our core business to ensure that we maximise the impact of our funding for our patients? It is unlikely that anyone would argue that we should not. Should we do this at all cost? One would expect a unanimous ‘no’. But, is it not then our core business to maximise the return from our investments within the framework of our principles and ethics (even, when this takes us out of our comfort zone)? The authors of this paper would argue ‘yes’. Investing in and developing partnerships with organisations that are experts in their areas is therefore essential to maximise MSF’s impact and efficiency. If we choose not to, we risk being MSF-centred, rather than patient-centred.

Investing in and developing partnerships with organisations that are experts in their areas is therefore essential to maximise MSF’s impact and efficiency. If we choose not to, we risk being MSF-centred, rather than patient-centred.

Such partnerships — whether corporate, academic or civil — can play a role at all stages of MSF’s innovation process. However, we perceive the real value to be during the development and implementation phases. For example, although MSF does have much experience in developing innovative solutions to field problems, turning these into finalised products and services has proven harder — we do not have manufacturing or distribution (as a vendor) expertise. Developing these capacities to serve MSF at scale would require huge investment, and would be a potentially dubious use of our resources. However, there are many organisations, keen to work with MSF, for whom this is core business.

Distrust versus tangible risk

The barrier to meaningful partnerships often comes down to a lack of trust. We distance ourselves from organisations who have profit or reputation motivations, because we perceive ourselves as being above these (or, at least, outside of them). For the same reasons, we struggle with the idea of intellectual property (IP) ownership, licensing and financial gain as an organisation. These instincts, rather than a pragmatic assessment of cost, benefit and risk in any given situation, can end up guiding our actions.

In fact, the authors of this paper would suggest that IP is something of a red herring in MSF’s discussions on partnerships, as we tend to associate it with teams of lawyers and litigation. In fact, there are a multitude of business models for products and services, which can be leveraged to scale their impact. MSFers should be aware of the opportunities and risks associated with these models in order to achieve the greatest benefit to our patients.

At the other end of the spectrum in these discussions is the idea that MSF could profit financially from product or service development. It is not the position of the authors that this is a path that MSF should take, but we would like to challenge the assumption that this necessarily crosses red lines in terms of ethics and principles. If a future can be imagined — as some already do — where NGOs and charities do not enjoy the level of private financial support available today is it unethical to develop a sustainable income models from the innovative products we co-create and reinvest this into MSF for our patients? Is it unethical not to?

Empathy leads to mutual benefit

If we are prepared to accept that, in the real world, MSF pursuing efficient innovation projects based on a patient-centred, ethical approach could lead to collaborations with organisations that are profit driven, the question then becomes ‘what new opportunities will arise?’ Based on the recurrent problems in MSF’s approach to date, we would argue that increased empathy will not only strengthen potential collaborative relationships, but also MSF’s own hand in understanding the world in which it operates.

One such example of this would be how an increased understanding of market dynamics gives MSF a stronger grasp of how and when to approach potential partners (and with what aim). During the internal research phase of the Innovation Partnerships Project (IPP) — which aims to increase MSF’s capacity to engage efficiently with external partners — we saw that thinking about the wider market potential (outside MSF) of innovative products is rarely done. This in turn makes it much harder for MSF to engage companies with a for-profit motive rather than just a corporate social responsibility exercise (which themselves rarely prove fruitful due to the lack of incentive). Taking the example of an organisation like PATH, which focuses a large proportion of resources towards understanding the market-dynamics around a particular topic, we can see how this enables them to engage in a more direct and efficient way. By calculating what the potential value of an innovation will be — both within the MSF ‘market’ and outside (including other NGOs, Ministries of Health and wider sectors) — we can approach potential manufacturers or partners in a way that makes it clear that engaging with MSF will be of mutual benefit by showing that X amount of units can lead to X amount of profit at a price we consider reasonable in terms of ensuring access.

Is this a satisfactory outcome? In our view, yes, but perhaps — should MSF had fully understood the value it added through its expertise — it could have argued for a stake in the final product itself.

A case study relevant to this approach is the Autoclave project, run by the MSF Sweden Innovation Unit, in collaboration with OCB. In this case, a gap in the market was identified by the Biomedical working group and through significant analysis of the gap that this new equipment needed to fill, a partner producing similar equipment was identified. During the project, the partner was convinced of the potential value of the device on the wider market, making it possible for them to invest up to 50K EUR of their expertise and time to produce a working prototype which has run thousands of cycles in our Haiti project. Now, more devices can be produced at a price MSF is willing to pay for. Is this a satisfactory outcome? In our view, yes, but perhaps — should MSF had fully understood the value it added through its expertise — it could have argued for a stake in the final product itself. It’s also worth pointing out that, through the process of engaging actively and information sharing with external experts, we were able to identify a potentially harmful gap in our infection prevention and control protocols for the specific type of sterilisation which has now been addressed.

As we have seen in this project and others, when we are willing to engage in an open and fully collaborative way with a company that understands there is a profit incentive for them to work with us, there is a real opportunity for a wider benefit to arise. The company understands our needs better and mutual trust is gained. If we are to pursue similar longer-term partnerships, can this be the way to increased efficiency? For example, if based on our experience we are to consider partnerships with law firms that provide us with pro bono advice, it would definitely seem so. One recurrent theme that has also arisen from the IPP is that briefing legal advisers on the priorities of MSF (not profit, but access) can be time consuming and, thus, expensive. By engaging with external partners — be it academic, commercial or other NGOs — building longer-term understanding and trust can only be a good thing.

The type of partnership: Transactional - Transformational

Many partnerships are transactional. These are partnerships where each partner has a clear understanding of what value is being transferred, and for what price. There is no collaboration, and value is pre-defined before exchange. These partnerships can be seen in client-vendor relationships, and in the majority of NGO - institutional donor relationships. Even in innovations, there are often such relationships. These relationships can create value, but that value is usually pre-defined, and assigned to one of the parties, such as paying a software developer to create a programme.

At the other end of the spectrum are transformational partnerships. Such partnerships create shared value, where the value goes beyond the transactional exchange of the value, to creation of new value (sometimes unanticipated) across multiple spectrums, including, but not exclusively; patient impact, organisational capability, policy and process changes, profit. Such partnerships can create significant impact for patients, and if they do create sufficient revenue, it can assure sustainability of access as well. Innovation in such transformational partnerships often goes beyond the service of the product and include the process and potential business model innovations. An example of this could be the Cold Chain Indicator project, which aims to develop a much cheaper alternative to existing cold chain monitoring technology. Although the results may not be on the market for 5-10 years, should it reach the humanitarian market, MSF will have been responsible for kickstarting a collaboration that could simplify and drive down the cost of cold chain monitoring to a fraction of its current level for the whole humanitarian sector.

A key dynamic of transformational partnerships is the willingness of the partners to compromise. Intransigence is the enemy of successful partnering. Transformational partnerships that create shared value that can be scaled will only happen where partners are willing to compromise, and find solutions to potential areas of misalignment. This reinforces the need for MSF to be clear on what we will and won’t compromise on. With our ‘guiding star’ being what is best for patient outcomes, and not what is best for MSF.

Short term - Long term

There has been an assumption, and some evidence, that transformational partnerships take time to build. This is primarily because trust and openness take time to build, and shared understanding can only emerge through dialogue. This creates a potential time challenge for humanitarian innovation partnerships in two ways:

  1. Firstly, innovations can often be exploratory and if done well, can have rapid cycles and often change or pivot. With pivoting, comes the potential for partnerships to become misaligned. Also, in a number of cases, partners for one stage of the innovation (say invention), may not be the right partners for scaling an innovation, as they are unable to scale quickly enough. This is a problem facing a number of organisations as they seek to scale their innovations across the globe.

  2. The second area of challenge is the ‘humanitarian’ (and often ‘emergency’) aspect. Particularly for rapid responses, creating context-specific innovations can be in contexts that are dynamic and unstable, leading to context change before the complete innovation cycle is complete. If the innovation is not transferable, there is the potential to just create a product, service or process that doesn’t have a chance to deliver shared value. It can also mean that rigorous research and evaluation of the innovations impact cannot take place. Leaving it unable to provide the evidence base necessary to justify scaling.

Another issue faced by partners of humanitarian organisations in emergency settings, is the high turnover of staff. Something that can significantly stymie both the development of the innovation, and the relationship between the partners.

Bilateral & Multilateral partnerships

Many of MSFs partnerships are bilateral. Truly transformational partnerships that deliver sustainable and scalable patient value are often multi-lateral. Such partnerships require significant levels of compromise, and often take more time to establish. An example of such a partnership is the Missing Maps project, where multiple stakeholders (NGO, academic and, to a lesser extent, civil society and corporate) collaborate on a single project with shared objectives and principles. Each organisation brings something different to the table (for example, tech development expertise, field experience, volunteer bases) and the value of these contributions is shared.

In partnerships where private sector, MSF and the MoH of a country are involved, the likelihood for there to be sustained impact for patients is high.

Partnering and business Models

One of the most significant impacts of partnerships is the potential they have for diversifying NGOs' business models, whilst creating and delivering longer-term value for disaster affected communities. Once organisations go beyond transactional, towards transformative relationships, the way value can be shared over time expands. Just a few examples are:

Preferential Pricing — where Ministries of Health and NGOs receive discounted prices for a period after the collaboration on an innovation.

Volume — long term relationships can enable purchasing commitments over longer periods of time, and in some cases collective purchasing, strategies that can lead to economies of scale for manufacturing, leading to, lower pricing.

Revenue Models — partnerships can open the door for more innovative payment mechanisms, such as subscriptions, renting/leasing, pay-per-use.

Intellectual Property — although MSF should not seek to become a manufacturer, or a business, it could retain intellectual property for innovations and then licence them for profit making companies to produce. This is something that other innovative NGOs, such as PATH and DNDi have done.

Policy and Process Changes — such as joint advocacy regarding ‘on’ and ‘off’ label use of drugs, or getting a vital drug placed on the Emergency Medicines List.

Branding — leveraging each partners’ brand.

Capabilities — what other capabilities do partners MSF works with have, that could be leveraged ethically for humanitarian purposes?

Conclusion - Partnering for impact

There are many other potential benefits to partnering for innovation. But most of all, partnerships enable MSF to focus on our mandate and get the most out of our capabilities. Partnering with others who have different capabilities can deliver better outcomes for our patients. Partnering in the right way will increase MSF’s effectiveness and efficiency, and will ultimately lead to greater impact for patients.