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EF: If you were to create a new start-up in the healthcare sector, what would it be? 

ZB: The field of research, development, and manufacturing of medicines is already well-established, particularly with the remarkable innovations coming out of the pharmaceutical sector right now. Instead, I would create a start-up that focuses on managing and building efficiencies in healthcare ecosystems. This is something South Africa and the rest of the African continent need to prioritize. We must develop healthcare ecosystems that decentralize healthcare and bring it closer to the communities in which people live and the people ultimately served by healthcare. This would encourage early healthcare-seeking behaviour and provide services to those who need them most. 

For instance, we are part of a global initiative called Investing in Innovation (i3) which is apan-African support initiative for African health supply chain start-ups,funded by the Bill & Melinda Gates Foundation and sponsored by MSD, the World Health Organization (WHO) Regional Office for Africa, and Amerisource Bergen. The initiative unites leading donors, industry, and African institutions to jump-start a new way of doing business to support African-led innovations in health. Currently, the initiative supports 30 start-ups from 14 countries across Africa, almost 50 % of which are women led. The selected start-ups will receive a $50,000 grant (risk-tolerant credit) and access to market opportunities to catalyse growth driven partnerships with donors,industry, and institutional stakeholders. These start-ups are driven by finding solutions that drive efficiencies in health eco-systems, improving access to healthcare and incentivising better health seeking behaviour.

When healthcare is sought early on, it's more likely to prevent downstream disease burden when diseases have progressed – ultimately leading to health savings. An example of innovation among health start-ups that improve health ecosystems and health seeking behaviours is “Unjani Clinics” in South Africa. Unjani Clinics is a clinic network which empowers nurses to set up clinics, through refurbished shipping containers, placed in underserved communities where they often come from. These are private businesses with a capitation fee model. The nurses own the business,but there's a two-year handholding process, after which they graduate and take full ownership of the facility. The genius in the solution is that the clinics enable the nurses to take care of a large population of people who may not have the kind of disposable income to access the private healthcare system fully. At the same time they can also take care for those who work and can’t afford to take a day off to be serviced by the public healthcare system, which is often characterised by long queues, sometimes at hospitals. These are the people who tough it out when it comes to their healthcare.  

These clinics allow people to seek healthcare within the spaces in which they live in acost-contained model. Several pharmaceutical companies, including ourselves,support the clinics and the growth of the network. This facilitates the improvement of the healthcare system as a whole because in addition to the work they do, they also they also have partnerships with the government with some medicines and government patients being funnelled through these clinics,decreasing the volume of patients in already overburdened public healthcare spaces. They are effectively the ideal plug-in for an NHI or UHC system and we,as health partners, need to focus on how this model can be scaled into as many communities as possible within South Africa and figure out how we can take this model and move it into other markets within Africa as a whole. 

EF: Beyond start up investments. How important is it that organizations get involved in skills development initiatives to create an attractive work environment and encourage active economic participation for young talent?

ZB: MSD is a company that is very focused on diversity and inclusion endeavours and activities. Ithink that as a company that's operating within South Africa, given the history that South Africa has, we don't have a choice. A diverse and inclusive environment is a necessity. If you live in an environment where the economy is not inclusive, you will inadvertently have an unsustainable market downstream.

If you look at the unemployment rate in South Africa, I think it's sitting in the region of about 32.7% while youth unemployment is estimated to be around 63.9%. I can tell you that if you're not actively intervening, you'll have a problem down the road. So our focus has been to ensure that, as an organization, we are reflective of the country, in terms of race, gender and the age demographic and we’ve made good progress in this regard. We've also focused a lot on the youth through creating learnerships as well as partnering with the YES Initiative. Through that, weare taking young graduates straight into the world of work and giving them meaningful work experience.

And fortunately,we've managed to absorb quite a number of them into MSD as they came to the end of their learnership. Many who also left mid-program or after the program have found employment and we like to believe it is in part due to the opportunities we provided that gave them the experience required for them to be absorbed into the world of work. As MSD, we did this and continue to do so because we believe we have a responsibility to as a responsible corporate citizen and we had the Deputy Minister of Higher Education, Science, and Innovation,  Mr Buti Manamela come to our campus to help us launch this year's intake of graduates, celebrate this work, and shine a spotlight on what we've done to support diversity, equity & inclusion which has culminated in achieving a level 4 B-BBEE contributor status.

B-BBEE is important because it's indicative of how, as an organization, you are investing back into the economy. Over the past two years, we've managed to go from non-compliant to Level 4 and this is something to be celebrated. I believe that the responsibility of government is to create an enabling environment and our responsibility as an organization is to execute and implement legislative requirements that are for the general benefit of the South African populace at large. This is something that we live on a day-to-day basis, and I'm incredibly proud of the achievements that we've had in this regard. I'm extremely proud of the young people that we've developed who have come out of our program and are beginning flourishing careers. I'm also proud of the fact that, as a multinational organization, we managed to reach Level 4 BBBEE status, which is something that requires a collective effort across all pockets within the organization.

EF: What are your thoughts on the need for an integrated healthcare model? 

ZB: The National Health Insurance (NHI) is an absolute necessity. Healthcare is not a privilege,but a right that should be accessible to all. Having said that, the NHI must guard against the risk of regressive realization of healthcare rights. Under the NHI, a person who has access to a particular type of healthcare system and quality healthcare interventions should not experience any reduction in the quality of care. Instead, the NHI should ensure that everyone has access to the highest quality healthcare that the country can provide, whether it be from the government or private healthcare players. The distinction between a private and public healthcare system creates a divide, but there is only one healthcare system, and it is under the custodianship of the Ministry of Health. Our collective role is to provide the best quality service to everyone.

This is the importance of the Presidential Health Compact, and why we, as pharmaceutical companies continue to support Pillar 2 of the compact which focuses on ensuring sustainable access to essential medicines and within this, it is critical that we enable the regulatory reform as it relates to pricing regulation, in terms of inter-country visibility of net prices of medicines, and the integration of alternative reimbursement models which enable risk-sharing between manufacturers and payors to enable sustainable patient access to evidence-based medicines based on need and not affordability.

EF: How do you balance the communicable and noncommunicable burdens in South Africa? 

ZB: The focus is on developing a long-term runway and starting work on it now, which allows people to progressively realize their healthcare rights. Access to healthcare and its quality should progressively increase and improve. The key challenge in South Africa is how to sustainably provide innovative healthcare to the majority of the population. Conversations around cancer care are on the rise, alongside parallel improvements in available therapies. For a country as ambitious and capable as ours, we have not yet hit the right note in expanding healthcare,particularly innovative healthcare, to the majority of South Africans, within both the private and public healthcare systems. 

I am however very encouraged that at the recently held Presidential Health Summit, there was broad acceptance that government needs to employ a more nuanced access approach for treatments for rare & deadly diseases that may not have significant patient numbers. Public sector tenders usually do not work in these instances due to the lack of volume whilst access is also minimal in the private sector primarily due to a lack of reimbursement. The NDoH has been urged to meet with manufacturers, funders & patients to co-create a framework for the implementation of alternative access mechanisms that will broaden access in both the public & private sectors.  

Through IPASA, we have started a process with other stakeholders, such as funders and healthcare practitioners, and collectively formed a body called the Alternative Reimbursement Model (ARM) Steering Committee. This committee focuses on how to sustainably expand access to innovative medicines, which can be costly. We have developed models that could improve access to healthcare and address issues of affordability for South African citizens. We've engaged a consulting company to facilitate an engagement between ourselves as the Steering committee and the Ministry of Health to say, "These are our ideas for improving access, these are the models we think could be implemented. How do we work together with the MoH to co-create a solution that we can collectively trial and implement."The overarching idea is that these innovative solutions that we are proposing could plug into  NHI and thus ensure that under the NHI, patients and the population at large will be able to access innovative healthcare in a manner that manages budgetary considerations as well. We need to find a sustainable and viable means of broadening access to innovative healthcare in South Africa. 

EF: What is your perception of personalized treatments and gene therapies and how are they going to shape the future of healthcare in South Africa? 

ZB: We need to start focusing on access long before products become available.  Today,developments made are being accessed in Western markets first, and Africa lags significantly behind in terms of access to these medicines and I believe we’re all doing patients a huge disservice. My overarching goal is to ensure that when an innovative product is launched, it should be fully accessible to all patients, whether they are accessing healthcare through the private sector or the public sector and regardless of where you live on the Continent.  

We need to engage with governments and formulate a road map that contemplates a fairly good sense that it will be available in the market in four or five years post the registration process. Being able to engage beforehand with the government would significantly improve access to medicine. Today, these products are developed,registered, and immediately available in the private sector, where people have private healthcare insurance. The public sector will usually only access these when generic alternatives become available after the patent has lapsed.  

One of the biggest misunderstandings that people have is that we are not aware of the budgetary constraints that the government has. This is exactly why we want to have the conversation and these workshops on ARMs because we tend to avoid having difficult discussions upfront, and what we want to do is have these discussions in a product-agnostic way, develop the processes that will ensure that we take care of, and address the budgetary constraints that the government has, and then plug in the product from whichever manufacturer at the most appropriate time based on the unmet needs of the population. 

It's an important discussion to have because it speaks to the impact and efficiency of what it is that we are doing. If we are not treating patients, then we're not doing ourjobs collectively, and I speak not just as someone who heads up a pharmaceutical company and who is president of IPASA, but I'm speaking as someone who is a South African citizen who has to access the very same healthcare system that we are talking about now. It's about building robustness and building efficiencies and quality within the space. 

EF: What do you see as the role of artificial intelligence and technology in drug development, and can we adopt this in South Africa? 

ZB: AI, at its very core, is a conversation about data, its availability, and what it does,particularly in resource-constrained environments. It gives you the ability to deploy resources efficiently. It goes back to that initial question that you asked about what kind of start-up one would be focused on because that's exactly what we need in Africa. I was at the AMREF AHAIC conference earlier this year, and I participated in a panel where we spoke about the burden that healthcare workers are under. They are burdened by under-resourcing, too many patients, and patients not having access to healthcare in their immediate areas. Data allows us to determine that we don't treat all places equally. Some places need a little bit more energy and resources than others. 

Data also allows you to deploy resources in accordance with the disease patterns of specific areas.Generally, Africa has a challenge regarding data reservoirs. There's also the issue of what type of data can be shared across borders. There are data security issues that come into play. I think the AI discussion in this regard would revolve around health system resources and specifically what those areas require. I think if we can do that, it will certainly avail better quality services to the people at the end of the day. It's not about our medicines or the doctors, but about the quality of healthcare that's being disseminated to patients at the end of the day. 

EF: The healthcare sector is heavily regulated and obtaining data within the sector can be challenging. What regulatory changes do you believe are necessary to improve data security and sharing? 

ZB: The issues surrounding security and data sharing can always be resolved. I believe that there are definitely ways to do it. The most important thing is that we need willingness across the board. We need the private sector to be willing to disclose their technologies that can aggregate data, effectively analyse,research, and develop outputs. We need policymakers to be willing to generate effective policies that allow for the sharing of data. What you will consistently hear from multiple parties and myself is that no one can do it alone. Purposeful collaboration between the private sector and the public sector is necessary to get it right. 

We are making progress, but in many instances, there is still some reservation, and that is why we are here. We are here to change the narrative. We are here to convince people and ensure that the ultimate outcome of the work we do benefits patients. I have had conversations similar to this with various policymakers and people in government, and I've never found a situation where we've disagreed on what needs to be done. We always agree on what needs to be done - it's how it must be done that we often find that there's a chasm and so we must focus on bringing that chasm together. I think the way to do that is through co-created solutions. We, as the private sector, went to the government or the Ministry of Health and told them what we did. We now tell them, "This is the ultimate outcome that we want to achieve. Are you aligned with it? Yes? If you are,let's get around the table and develop a solution that's going to suit your needs as well as ours, but most importantly, the patient's needs." 

That's exactly why we brought a consulting agency on board to help facilitate this work that we have to do. Because they are a neutral party, they will be able to get us to move beyond our own self-interested points of view, and they'll be able to independently say, "That's a big hurdle, but that one is not a big hurdle,so let's try and solve this one quickly. "We'll see how it goes, but it's a work in progress. 

EF: IPASA is going to celebrate its 10th anniversary. What achievements would you like to highlight in your celebratory speech? 

ZB: The effort and the work that's been put into IPASA is a collation of inputs from many people and many different organizations. I'm largely the mouthpiece of the collective,but I am in the trenches with all of them as we try and put forward policy and legislative changes that we believe are for the ultimate benefit of the patient. I tend not to focus on the fact that it's my one-year anniversary ashead of the body. I want to ensure that IPASA has a legacy hinged on ensuring broader access to innovative medicines for all. That's the one thing that we collectively exist to do. 

It's through the work that we consistently do with the Public Healthcare sector. All that we are consistently doing is working on ways and means of broadening access to medicines for patients and creating an efficient and sustainable pharmaceutical industry because sustainability is the one thing that is going to ensure that we can continually invest in developing medicines and ensuring that they are widely available in South Africa and the continent. The work that we do is largely about patients and about leaving a legacy that will ensure that South Africans and Africans at large have the opportunity to be healthier through accessing innovative medicines much sooner in the product life cycle. 

May 2023
South Africa