Global projections consistently demonstrate an escalation in both the incidence and prevalence of end-stage renal disease (ESRD). Using data from the United States Renal Data System (USRDS), the ESRD incidence in the US was estimated to increase following a linear trend1. More importantly, the prevalence is predicted to increase in an exponential manner such that Medicare expenditures for ESRD are calculated to exceed USD$28 billion by the year 20101. Similarly, global ESRD estimates demonstrate an increase in the total ESRD population in the world, which will exceed 2 million patients and reach an annual global cost of US$75 billion dollars2.
The global burden of ESRD only serves to emphasize the need to explore alternative models of funding costly chronic renal replacement therapy (RRT), so that chronic dialysis and transplantation become widely available. Already, marked differences in the availability of chronic dialysis care exist between developed and developing nations. In India and China, only 5 and 3 per million population (pmp), respectively, are accepted into dialysis programs, as compared to 166 pmp in the USA3. Indeed, in China, it has been estimated that the majority of incident ESRD cases do not survive because of significantly reduced access to dialysis or transplantation that directly results from insufficient funds4. Thus, in less developed countries where government funded ESRD care is restricted, chronic dialysis is available only to those with the economic means to pay for treatment3. In fact, even in nations such as the United States where federal support ensures sufficient funds for ESRD programs, individual differences in socioeconomic status continue to be associated with a wide variation in health outcomes5. In a study of Medicare-eligible hemodialysis patients within the United States, each USD$10,000 increase in income was associated with a 5% reduction in mortality, even after adjusting for clinical, behavioral and other known predictors. Similar differences in long-term morbidity and mortality have been observed in other chronic diseases6,7.
With the cost of care and the economics of ESRD being the primary barriers to widespread access to chronic renal replacement therapy; with socioeconomic status being a definite factor affecting health outcomes, and with the global concern for the continued increase in the incidence and prevalence of ESRD, we propose that novel approaches to providing chronic disease care should be considered. In this article, a unique paradigm of funding chronic dialysis care based entirely on the formation of several forms of public-private partnerships will be presented. This model, which continues to be a central and evolving paradigm for the National Kidney Foundation Singapore, illustrates the potential strength of such collaborations in addressing priority health concerns in the country8.
OVERVIEW OF PUBLIC-PRIVATE PARTNERSHIPS TO ADDRESS HEALTH CARE ISSUES
In the last decade, global health care bodies, such as the World Health Organization and the World Bank, have recognized that for many health care issues affecting economically challenged regions in the world, cross-sectoral collaboration between not-for-profit public institutions and for-profit corporations is required9. This relatively novel concept formalizes the sharing of expertise and resources toward the accomplishment of a common socially beneficial objective10. Beyond simply a matter of one partner providing funds or grants toward the accomplishment of a particular initiative, these partnerships are characterized by a balanced division of labor and resources, with a blurring of the conventional boundaries that separate for-profit and non-profit organizations9.
The major factor that gave rise to such partnerships is the recognition that for many large-scale health-related challenges, conventional approaches to program development traditionally carried out by the public sector can only yield limited results11. Such partnerships recognize that although each founding partner may be driven by different ethics and overriding motivations, for the purposes of a specific health care challenge, a convergence of strategies and goals is appropriate12. It is also believed that for both sectors, significant benefit can be derived by each of the partnering institutions. For instance, the public sector can gain knowledge and skills in areas such as product development, marketing, and sales, whereas the private sector can benefit from increased exposure and improved community branding9.
Public-private partnerships have been classified according to different criteria. Buse and Walt divide public-private partnerships according to: (1) degrees of combined governance (equal negotiation capacity vs. delegation), (2) nature of activity (consultative vs. operational), and (3) goals of the partnership (product-focused, services-oriented, among others)13. In a description of the International Trachoma Initiative, a joint venture between the non-profit Clark Foundation and Pfizer Pharmaceuticals, Barrett and others similarly use degrees of collaboration as the basis of classifying public-private partnerships14. In a concept known as the "collaboration continuum," partnerships can be characterized as solely grant giving at one end of the scale, progressing to the "transactional stage" whereby partners combine resources toward a common goal, to the "integrative stage" that is characterized by the merging of institutional resources in order to generate a new identity15. Regardless of the categorization of public-private partnerships, lessons from the limited number of such partnerships that exist worldwide suggest the need for a minimum set of elements that are required in order to succeed. These include: a commonality of goals, strategy and values; the formation of interpersonal relationships between partnering institutions; the creation of value for both partners; and concrete guidelines to facilitate feedback and communication. It also is recognized that there is a need for agreement on defining criteria for the evaluation of the extent to which a partnership has achieved its goals10,14,15.
Global illustrations of successful partnerships
It is in the area of infectious disease in less-developed countries that global public-private partnerships are most firmly established. In a database of public-private partnerships, the Initiative on Public-Private Partnerships for Health, where partnerships are classified according to disease targets, over 70% of all listed initiatives target tropical diseases, vitamin deficiency, AIDS, dehydration and other infectious-related diseases that affect less developed countries16. These partnerships have traditionally focused on new drug development for diseases that predominantly affect economically-disadvantaged individuals, and on the creation of drug delivery operational systems to facilitate the distribution of existing pharmaceutical agents17.
Two of the most recognized partnerships are the Mectizan Donation Program12 and the International Trachoma Initiative14. The Mectizan Donation Program is a partnership between Merck Pharmaceuticals and the Task Force for Child Survival in order to systematically donate ivermectin for the control of a debilitating condition, onchocerciasis, which if left untreated leads to blindness. As a result of this program, it is estimated that 200,000 individuals have been prevented from becoming blind18. Furthermore, the drug's use in over 11 African nations is thought to have resulted in a significant reduction in transmission rates of onchocerciasis19. Similarly, the International Trachoma Initiative (ITI) was a partnership formed between the Clark Foundation, traditionally a research funding body, and Pfizer Pharmaceuticals, in order to make azithromycin widely available for the control of trachoma, another condition that leads to blindness and is highly prevalent in African, Middle Eastern and certain Asian nations. Short-term clinical outcomes of the ITI have demonstrated up to 50% reduction in the prevalence of trachoma in pilot projects conducted in Morocco and Tanzania14. Common to these two partnerships is the identification of a unified mission: the provision of a pharmacologically effective treatment to communities that could otherwise not afford the cost of such treatment. Equally important is the recognition of each sector's specific need in the formation of such a partnership; that is, the acknowledgment that a partner enters an agreement for specific gains that may be unique to the individual partner. For Pfizer or Merck, the specific goal may be increased visibility or an enhanced public image that may indirectly result in an increase in sales of unrelated products, whereas for the Task Force for Child Survival or the Clark Foundation, the primary motivation may be the actual provision of the specific drug in order to achieve greater recognition of its impact and contributions to society.
Although the concepts of public-private partnership have traditionally been applied predominantly to infectious diseases in developing nations, we believe that these same strategies can be an effective means to address the public health issue of chronic kidney disease and its associated diseases. Furthermore, we argue that within an institution, several forms of public-private partnerships can exist simultaneously in order to address a unifying problem: the provision of affordable renal replacement therapy. Finally, we demonstrate from the experience of the National Kidney Foundation Singapore that implementing such partnerships can be of relevance even in a developed nation such as Singapore.
THE NATIONAL KIDNEY FOUNDATION SINGAPORE (NKFS) CLINICAL PROGRAMS
The NKFS' public-private partnerships are best viewed in the context of its clinical programs and other accomplishments. The National Kidney Foundation Singapore, the largest charitable organization in the country, was founded in 1969 with an initial mandate of educating the Singapore public about ESRD8. One of its early successes was its facilitation of the passage of the Human Organ Transplant Act in 1987, which assumes that a Singaporean aged 21 to 60 years is presumed to be a kidney transplant donor unless a specific objection was made during the individual's lifetime20. Singaporean Muslims are currently excluded from participation because of religious ideology, although the NKFS has initiated a campaign in partnership with the Muslim community in order to reexamine this exemption.
In 1987, because of the realization that over 95% of the country's ESRD population was dying because of an inability to afford chronic renal replacement therapy, the NKFS initiated a program to provide subsidized chronic dialysis therapy. In Singapore, healthcare is predominantly financed by a mandatory medical savings account known as Medisave, a monthly savings account that amounts to 6 to 8% of the individual's income. For chronic replacement therapy, a maximum of US$257 per month (Singapore $450) can be used for chronic dialysis. An additional US$570 to $1430 per month (Singapore $1000 to $2500) can be utilized from an optional medical insurance scheme that can be purchased from the government. However, 40% of the total NKFS ESRD population do not have access to this medical insurance scheme. Indeed, for the majority of ESRD patients, an additional US$1000 per month (Singapore $1750) would need to be paid for out-of-pocket in the absence of subsidy, solely for the direct costs associated with chronic dialysis treatment.
With the above in mind, the NKFS set about establishing what has become the largest single dialysis network in Southeast Asia, which currently provides chronic dialysis care to over 70% of the country's total ESRD population21. It provides up to 96% subsidy for all direct costs related to dialysis treatment, with intermediate clinical and mortality outcomes that are at least comparable to those achieved in the United States (details on NKFS paradigm of funding ESRD care and its resulting clinical outcomes are in8). Furthermore, the program's rehabilitation outcomes demonstrate that close to 90% of ESRD patients considered as eligible for employment [excluding those older than 60 years of age (Singapore's retirement age), students, housewives and the 4.4% assessed by the medical staff as medically unfit for employment] are fully or partially employed. In contrast, studies in the United States of ESRD patients 62 years or younger demonstrate employment rates ranging from 11 to 24%22,23. This high employment rate has probably been achieved through direct financial motivation of the ESRD population, in that patient subsidy is matched to an individual's success at personal rehabilitation, as well as through partnerships with private corporations that do not discriminate against the employment of individuals on chronic dialysis.
Because of the rising annual incidence of ESRD in Singapore, in general, and the increase in both the incidence and prevalence of dialysis treatment at the NKF, in particular24, the NKFS expanded its focus to include the prevention of kidney disease and its associated chronic diseases25. Stepwise primary, secondary and tertiary prevention initiatives were designed to address obstacles to care at each stage in the development of kidney disease among individuals at risk for the development of ESRD. These include nationwide surveillance for urinary abnormalities, hypertension, diabetes and other recognized risk factors for kidney disease, the development of a network of NKFS Prevention Centers, which provide secondary screening for detected abnormalities as well as comprehensive team-based care for patients with known diabetes and hypertension. The NKFS Prevention Program is comprehensive in breadth, as well as in reach. Already over 800,000 Singaporeans have participated in its nationwide screening program, representing over 30% of the country's total adult population in the year 2001. Based on this screening program, novel predictors for proteinuria have been identified in this uniquely Asian population including mild elevations in systolic and diastolic blood pressure, both extremes of body mass index, and a family history of renal disease26. Similarly, based on the NKFS pediatric screening program, a low current body weight was identified as a significant predictor for proteinuria27. Both short- and long-term clinical and economic outcomes are being monitored in order to evaluate the efficacy of this comprehensive prevention program. Furthermore, clinical data derived from the surveillance, as well as the intervention program, will be analyzed and incorporated as the prevention program and the NKFS continue to evolve to respond to the population's healthcare needs.
Social entrepreneurship at the NKFS: Developing public-private partnerships to fund chronic disease care
The success of the NKFS as a charitable organization is based on its recognition that not-for-profit organizations are not only measured by the social impact that they create28, but through responsible and transparent use of donated funds8. In addition, the NKFS recognized early on that an entrepreneurial approach is vital to a charitable organization's long-term sustainability. Indeed, social entrepreneurship as a formal entity has only recently attracted attention29. However, the NKFS has long been oriented toward the identification of opportunity, the pursuit of innovation, the importance of a clearly defined strategy, and the positioning of a proposition (whether to another not-for-profit organization or to a private corporation as a partner), characteristics that define entrepreneurship and which have traditionally been associated solely with for-profit corporations28,29. NKFS' response to the nation's healthcare needs, with the accompanying recognition of the opportunity to impact on public health at a nationwide level, propelled its evolution from a mere knowledge provider and a vehicle for public education, to its current status as the largest single dialysis provider in Southeast Asia. Its mandate most recently has expanded to include the implementation of programs and services to serve the entire population at risk for chronic kidney disease through chronic kidney disease prevention strategies. In its fundraising initiatives, the NKFS has always utilized fundamental business methodologies such as customer relationship and database marketing in order to generate funding for its numerous clinical initiatives. Indeed, one of the most novel aspects of the NKFS is its unique model of funding kidney disease prevention and chronic dialysis care based entirely on charitable donations. The NKFS' predominant strategy for generating sufficient funds in order to sustain its clinical programs is through the formation of partnerships. NKFS' partnerships are characterized by varying degrees of collaborative relationship, representing each stage of the "collaboration continuum" as defined by Austin15. Established partnerships range from conventional donations, progressing to active engagement toward the implementation of a pre-defined collaborative project, to full-scale integration with the resulting formation of separate institutions and joint ventures. Given the number and scope of NKFS' partnerships with corporations, healthcare institutions and other publicly funded organizations, it is beyond the scope of this discussion to describe each of the partnerships in detail. Instead, specific examples will be used to represent each type of NKFS partnership.
Partnership with corporations
In its attempt to accomplish one of its missions, that is, the provision of highly standardized chronic dialysis that is affordable to all, the NKFS recognized the need to work with strategic partners that could share the risk involved with establishing such a program on a massive scale. In the early stages of this program, the natural choice for partners would be pharmaceutical companies that are actively engaged with manufacturing and distribution of dialysis-related products. In the earliest forms of partnerships, the NKFS worked with companies such as Fresenius, Inc. and Baxter, Inc., in order to provide dialysis machines at much reduced cost. Indeed, even recently, in an initiative to expand national treatment options for ESRD, Baxter, Inc. formed a partnership with NKFS in order to establish a national peritoneal dialysis program. This not only involves the provision of equipment related to peritoneal dialysis, but also includes the development of active training programs for both allied health professionals and patients. Similarly, the NKFS identified a pharmaceutical company, Janssen-Cilag, as a partner in its attempt to ensure the widespread availability of erythropoietin for chronic dialysis patients. Through this partnership, ESRD patients of the NKFS purchase erythropoietin at less than 50% of market costs. In using terminology from the "collaboration continuum"15, these relationships are representative of the "transactional stage." Indeed, more than simply reducing the cost of drugs, equipment or services, each of the partnering corporations continues to work with the NKFS in dialysis program development, patient and general population education, as well as the training of allied health care professionals. This interest in continued partnership has been further enhanced by the demonstration of concrete benefits for both sides of the partnership. For instance, through the NKFS partnership with Janssen-Cilag, the foundation benefits by providing its patients with an otherwise unaffordable drug, erythropoietin; while for Janssen-Cilag, the improved public relations may translate to potentially improved sales to both the NKFS and the general public, even for unrelated products.
In response to the need to expand the national dialysis program, the NKFS proceeded to work with private corporations. In order to address the need to build two to three dialysis units each year, the NKFS has developed partnerships with Singapore Airlines, the SUTL Group of Companies, and Singapore Pools, among others. For each of these partnerships, capital and recurrent costs of establishing the dialysis unit were provided by the private corporation, whereas the NKFS was responsible for developing the infrastructure, providing the technical knowledge, and fulfilling the manpower needs of the facility. Each partnering corporation is involved further with clinical and rehabilitation outcomes monitoring of the respective dialysis unit. Thus, by identifying private corporations with a "social conscience," the NKFS has been able to ensure the availability of chronic dialysis treatment. In return, the private institution is ensured the transparent and appropriate handling of funds to achieve the collaborative mission of providing dialysis care. Furthermore, their partnership with the NKFS enhances their public image as a company that exemplifies the best norms of philanthropy, which may indirectly result in an improvement in the private corporation's own business.
NKFS also has established partnerships with over 70 private small and large-scale businesses in Singapore toward the development of an employment program for patients with ESRD. These private corporations acknowledge that even patients with chronic illnesses can be contributing members to the workforce. To facilitate this process, the NKFS has a separate team that manages a job placement service to match the skills of ESRD patients to the requirements of the hiring company. Indeed, the over 90% employment rate of the NKFS ESRD population is partly attributable to this "Job Connections Program."
Partnership with healthcare institutions
In addition to working in partnership with for-profit corporations, the NKFS has established collaborative relationships with healthcare institutions. In the initial stages of the NKFS' attempt at working with local nephrology healthcare providers, its efforts met significant resistance due to the creation of competition for services with private dialysis centers. As a result, the NKFS established independent partnerships with medical institutions outside Singapore, most notably that with the Brigham and Women's Hospital (Boston, MA, USA). Over time, with increasing support from the local nephrology community, the NKFS was able to formalize its relationship with local healthcare institutions. Hospital-based nephrologists are now part of the staff that provides direct patient care to NKFS dialysis patients.
Some of the NKFS' partnerships with other healthcare institutions represent the most formal of partnerships, known as Austin's "Integrative Stage"15, in that separate joint ventures are created in order to fulfill a newly identified mission. One primary focus for the NKFS' programs is the pediatric renal disease population. Given that the only pediatric renal replacement program in the country was a small dialysis program established by the NKFS, a more comprehensively structured and dedicated pediatric kidney disease and dialysis facility needed to be created. The NKFS identified the National University Hospital (NUH) as the appropriate partner to establish this program. The pediatrics department at the NUH was the logical partner, since it was the only facility in Singapore with physicians and nurses appropriately trained to provide chronic dialysis to infants and small children. In order to raise funds to support both capital and recurrent costs for the facility, the NKFS worked with another not-for-profit institution, the Shaw Foundation, with which the NKFS has had a long-standing partnership. With these three organizations, the NKFS, the Shaw Foundation and the NUH, a new entity, the Children's Kidney Center was established. This facility, housed at the NUH complex, has separately defined medical and management bodies, thereby reducing the likelihood that the Center's identity might be subsumed under that of either founding institution. Partnerships with research and academic institutions are currently being evaluated also, including the formation of a separate NKFS Molecular Research and Genetics Unit in a partnership with one of the nation's leading research institutions.
Partnerships with other non-governmental organizations
The NKFS has long recognized that the formation of partnerships with other non-governmental organizations and organized religious groups represents a natural synergy and convergence of their respective missions and social responsibilities. Indeed, the most established and successful of NKFS' partnerships have been formed with not-for-profit organizations such as the Shaw Foundation, the SUTL Group of Companies, the Lee Foundation, and organized religious groups such as the Kwan Im Thong Hood Cho Temple and the Buddhist Welfare Services. For all of these organizations, there is an overriding commitment to benefit the community by utilizing resources that may have been contributed by their respective supporting donors, in the case of religious groups, or accumulated wealth, in the case of private foundations. These partnerships encompass various components of the NKFS programs, with one institution generally working with the NKFS to accomplish more than a single initiative. For example, the Kwan Im Thong Hood Cho Temple has worked with the NKFS to establish not only the single largest dialysis unit in Asia, but to develop the NKFS Nationwide Screening Program. Similarly, the Shaw Foundation worked with other institutions to provide funding for the construction of the NKFS headquarters building, in addition to establishing the Children's Kidney Center. Degrees of partnership vary according to the specific project rather than to the partnering institution. For instance, the Kwan Im Thong Hood Cho Temple is intimately involved with the operations as well as clinical outcomes of the nationwide screening program, whereas it plays a less prominent role in its dialysis program.
Partnerships with private individuals
One of the NKFS strongest forms of partnerships involves its unique relationship with the general public. Regular personal communication with up to 65% of the country's total population is ensured by traditional business principles of customer relationship marketing. This process ensures that the individual's communication preferences, whether through telephone conversation, e-mail or direct mass mailing, are recognized and addressed. Fundamental to maintaining this partnership with the general public is the maintenance of transparency in the handling of funds and the fulfillment of delineated objectives. Indeed, details on the use of donated private funds are reported annually to the private individual donor in the form of an "Investment Report."
SUMMARY
With the recognition that chronic kidney disease is a public health concern30, novel strategies to address renal disease prevention and chronic renal replacement therapy need to be identified and implemented. The NKFS has demonstrated that public-private partnerships to address urgent health care issues need not be limited to infectious diseases in developing nations. Indeed, the NKFS has developed several forms and degrees of partnerships with various stakeholders, thereby filling a healthcare need of providing chronic dialysis care in a developed country such as Singapore. In fact, these same partnerships have expanded in role to form a nationwide program for the prevention of chronic kidney disease. The accomplishments of these partnerships result from the identification of appropriate partners with common goals, whether these partners are motivated by business incentives or by social responsibility.
Given that the concept of public-private partnerships has been only recently formalized, many questions remained unanswered regarding the formation, assessment, and appropriateness of such partnerships. Guidelines on defining the effectiveness with which a specific partnership has accomplished its goals need to be developed, particularly in areas where success is defined by gained social value over and above clinical outcomes. This definition of success needs to be developed especially in the area of partnerships, which address chronic disease, given the long delay in defining improvement in clinical outcomes. In addition, ideal systems of governance for various forms of partnership need to be determined. Indeed, the overall predictors of a successful partnership to address chronic disease health issues need to identified, taking into account culturally specific nuances in the formation of partnerships. Nevertheless, despite these urgent research needs in the field of public-private partnership, the NKFS unique system of funding chronic disease care through charitable donations and through partnerships with various institutions deserves consideration, particularly in nations that have yet to establish dialysis programs. For nations that have sufficient representation of middle to upper socioeconomic classes, the NKFS experience demonstrates that, given the proper infrastructure and communication methodologies, the general public is willing to partner with charitable foundations to provide chronic disease care. For less-developed nations whose populations are significantly impoverished, the formation of public-private partnerships will be a unique challenge, since private corporations may not perceive that a "social investment" in these markets is profitable. However, with increasing globalization, the formation of public-private partnerships that do not recognize national boundaries may become increasingly more attractive as the impact of the partnership on international business is no longer tightly linked to geographic considerations. To this effect, the NKFS has formed a World Kidney Fund with the specific aim of educating nephrology health care providers in less-developed nations, imparting knowledge and skills relevant to fundraising, partnership development and business negotiation. Whether or not such an initiative results in concrete benefits in these nations will be closely monitored by the NKFS.
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