THE INTERNATIONAL COMMITTEE OF THE RED CROSS (ICRC)

As the world’s largest humanitarian network, the International Red Cross and Red Crescent Movement engaged tens of millions of volunteers around the globe.8 Organizationally, the movement consisted of three components: the International Committee of the Red Cross (ICRC), the International Federation of Red Cross and Red Crescent Societies (IFRC), and 192 National Red Cross and Red Crescent Societies.9 While the movement’s three components were independent and administratively distinct, they operated under common statutes and emblems, conflict, as well as health and social problems.10

Established in 1863 and headquartered in Geneva, the ICRC was an impartial, neutral and independent organization with a humanitarian mission of protecting the lives and dignity of victims of armed conflict and other violent situations, and providing them with assistance. The ICRC was a key player in the origins of the Geneva Conventions and the International Red Cross and Red Crescent Movement.11 The ICRC directed and coordinated the international activities conducted by the Movement in armed conflicts and violent situations.

The Geneva Conventions granted the ICRC an exclusive, internationally recognized mandate to protect and assist victims of conflict and war.12 Therefore, in addition to the ICRC’s advocacy activities focused on promoting humanitarian principles and respect for international humanitarian law, an important part of its work was to provide and support needs-based humanitarian assistance in areas affected by violence and its immediate aftermath. Humanitarian assistance entailed the provision of goods and services necessary to preserve life, prevent and alleviate human suffering, and maintain human dignity in situations where governments and local actors were overwhelmed or otherwise unable or unwilling to act.13 Examples included the provision of food, water, shelter and protection as well as medical assistance.

8 https://www.ifrc.org/en/who-we-are/the-movement
9 https://media.ifrc.org/ifrc/who-we-are/national-societies/national-societies-directory
10 https://www.icrc.org/en/doc/assets/files/other/statutes-en-a5.pdf
11 ICRC Mission Statement. Available at: https://www.icrc.org/en/mandate-and-mission
12 https://ihl-databases.icrc.org/applic/ihl/ihl.nsf/vwTreaties1949.xsp
13 ‘The European Consensus on Humanitarian Aid’ (2008), Official Journal of the European Union (2008/C 25/01). See: https://www.ghdinitiative.org/assets/files/Resource%20Center/General%20Principles/Core%20Humanitarian%20Principles%20%26%20Guiding%20Papers/10.-EU-Consensus-on-Humanitarian-Aid.pdf

HUMANITARIAN PRINCIPLES

As the delivery of assistance in conflict areas was fraught with ethical dilemmas, all of the ICRC’s activities were guided by the key humanitarian principles of humanity, impartiality, neutrality and independence (see Exhibit 2).14 These principles, which are enshrined in international humanitarian law, ensured that humanitarian assistance was carried out irrespective of the backgrounds of the people in need or the side on which they found themselves. The principles also stipulated that humanitarian assistance could not be influenced by political, economic, military or other secondary objectives, or influence the dynamics in a conflict. Three additional principles of the Movement also affected the Red Cross Red Crescent (RCRC) activities: none of its activities were to produce a gain (voluntary service); only one National Society could exist in each country and it needed to be open to all (unity); and the Red Cross Red Crescent movement as a whole had to operate worldwide and all National Societies had equal status (universality).

14 UN General Assembly Resolution 46/182, 1991

THE ICRC’S ENGAGEMENT WITH THE PRIVATE SECTOR

The ICRC had a long history of working with the private sector to promote humanitarian principles and objectives. These relations typically took the form of financial donations and contributions in kind. However, in recent years, the ICRC had pioneered deeper, more transformational forms of collaboration with the private sector to enhance its capacity to operate efficiently and meet humanitarian demands.15 While such collaboration was partially driven by the need for more resources to address ever-growing humanitarian needs, it also stemmed from the ICRC’s realization that the private sector was an inherent part of the humanitarian puzzle. This resulted in a desire to seek out and experiment with new ways of achieving humanitarian objectives.

More specifically, the ICRC collaborated with the private sector in the context of five “pillars of engagement”: to promote best practices and share analyses; to drive innovation and test new collaborative models and solutions; to leverage complementarity, assets, networks and skills; to collaborate with suppliers; and to mobilize resources through impact philanthropy.16 Each pillar represented a distinct avenue for value generation with the private sector. Potential partners were extensively screened on the basis of the ICRC’s strict ethical standards17 and a set of selection criteria. The latter included whether a company respected human rights, whether it engaged in controversial activities, and whether it was a leader in exhibiting CSR through policy and practice.18 The diligent screening of donors and partners based on these criteria allowed the ICRC to mitigate risks to its public image and its reputation.

15 https://www.novonordisk.com/sustainable-business/access-and-affordability.html
16 https://www.icrc.org/en/support-us/audience/corporate-support#five-pillars-corporate-engagement
17 https://www.icrc.org/en/document/ethical-principles-guiding-icrc-partnerships-private-sector
18 https://www.icrc.org/en/download/file/68119/ethical-principles-icrc-partnerships-private-sector.pdf

THE DANISH RED CROSS (DRC)

The Danish Red Cross (DRC) was one of the 192 National Societies that formed the operational backbone of the Red Cross Movement. Each National Society supplemented and complemented its home country’s government in helping people in need and working closely with vulnerable communities through a network of volunteers. Some National Societies also worked internationally, either through the ICRC or the IFRC or directly in partnership with other National Societies. The DRC had more than 20 National Society partners in Africa, Euro-Asia and the Middle East, which it supported in preparing for and responding to natural and man-made disasters in non-conflict situations. As such, the DRC’s international activities helped build the capacity of local National Societies to deliver services to vulnerable populations in the areas of disaster preparedness and response, health (including NCDs), and protection. In 2019, about half of the DRC’s annual budget was dedicated to international projects and activities.19

Of the National Societies, the DRC established itself as an expert in the area of mental health and psychological support, and it hosted the IFRC’s Reference Center for Psychosocial Support.20 The DRC was looking to develop NCDs, an area that had only recently began to attract more attention, as an additional area of expertise. Its vision was to establish itself as a facilitator and go-to-partner for other National Societies interested in working on this theme. In this regard, the DRC hoped to mobilize actors around NCD care and generate momentum to address unmet needs.21

To develop its capacity and meet growing demand, the DRC began to emphasize collaborating with the private sector. In particular, it believed that such collaboration could advance four objectives: to rally for change by mobilizing resources; to explore and innovate by developing better and more efficient ways of working; to engage people by using corporate networks to promote humanitarian values and advocate for humanitarian issues; and to grow responsible businesses by fostering sustainable, responsible and inclusive business practices.22 The DRC realized that meeting these objectives required experimenting with new forms of collaboration that went beyond fundraising and donations. An example was the DRC’s partnership with the Danish logistics company DSV, which financially supported the DRC’s international activities, and offered warehousing and logistics support for emergency relief 23 While eager to work with the private sector, the DRC was still exploring the best forms for such collaboration, including in the context of the complex challenges related to NCD care.24

19 Annual Report 2019, Danish Red Cross. Available at: https://www.rodekors.dk/sites/rodekors.dk/files/2020-07/aarsregnskab_2019_engelsk_2020_ok.pdf
20 https://www.ifrc.org/en/what-we-do/health/psychosocial-support/reference-centre-for-psychosocial-support/
21 Interview by the case authors, 26 January 2021.
22 DRC Guidance Note: Private-sector Partnerships.
23 https://www.dsv.com/en/about-dsv/corporate-responsibility/community-engagement/dsv-and-red-cross
24 Interview by the case authors, 8 March 2021.

PARTNERING FOR CHANGE (P4C)

As Morten Jespersen, the Danish Representative to the United Nations in Geneva, highlighted in his opening remarks during the panel discussion at the 2019 World Health Assembly, there was an urgent need for collaborative action on NCDs in crisis contexts. He highlighted that NCDs, such as diabetes, hypertension and cardiovascular diseases, were a class of chronic, non-infectious diseases that were highly debilitating and potentially lethal when not treated or managed correctly. The WHO estimated that each year, 15 million people died prematurely from NCDsand that more than 85% of premature deaths occurred in low- and middle-income countries.25 Although NCDs were beginning to feature more prominently on the global health agenda, they could not be addressed through single interventions, such as vaccines or antibiotics. Instead, they were typically more complex and required continuous care. Therefore, progress in improving NCD care was slow. In crisis contexts, providing NCD care was particularly difficult owing, for instance, to a lack of time, resources and capacity as well as aid workers’ limited awareness of the prevalence of NCDs among refugees, and the fact that refugees and internally displaced people often had other, more immediate health issues. Consequently, NCDs tended to remain undiagnosed and untreated among refugees. As a result, up to 25% of amputations in some of the ICRC’s physical-rehabilitation centres were related to diabetes.26

25 https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases
26 Aebischer Perone et al., (2017), ‘Non-communicable diseases in humanitarian settings: Ten essential questions’, Conflict and Health, 11:17.

THE FORMATION OF P4C

The seeds for a humanitarian partnership among Novo Nordisk, the ICRC and the DRC were sown when the ICRC initiated talks with Novo Nordisk at the World Economic Forum held in Davos in January 2015.27 That informal contact was followed by a more formal meeting regarding potential collaboration at the World Health Assembly held in Geneva in May 2015. The aim of that meeting was to explore Novo Nordisk’s interest in collaborating on building capacity for the management of NCDs in crisis contexts.28

At that point in time, the need to address NCDs was recognized in the humanitarian field, and the ICRC had already collaborated informally with several other humanitarian organizations on this issue. However, while much of the humanitarian community was sceptical of big business—and of the pharmaceutical industry in particular—the ICRC saw partnerships with the private sector as a useful complement to the efforts of humanitarian agencies. In particular, the ICRCbelieved that a partnership with Novo Nordisk, a company specialized in diabetes care and with an excellent reputation, could not only help promote awareness of the need to address NCDs in crisis contexts but also provide access to resources and expertise to better understand and find solutions to the needs of refugees and local populations with chronic conditions. A partnership with Novo Nordisk also suited the ICRC’s ambitions of going beyond donations and exploring new ways of partnering with the private sector.Similarly, the DRC had noticed that National Societies increasingly expressed a need to address NCDs. However, within the Red Cross Movement, there was little guidance on how NCD care could be integrated into other services, especially in humanitarian settings. The DRC believed that a partnership could help generate a better understanding of the need to address NCDs in crisis contexts, and guide the broader Movement and National Societies in their attempts to deliver better NCD care.The meeting in Geneva sparked several follow-up meetings during which representatives from Novo Nordisk, the ICRC and the DRC sought to define the scope, form and content of a possible partnership. However, progress was slow and intermittent in the subsequent years, especially because the partners had to first more precisely define what the partnership should entail. Often, initiatives presented under the banner of “cross-sector partnerships” were based on a model in which one partner “subcontracted” work, which was then “delivered” by another partner. In contrast, from the beginning, P4C was a partnership on equal footing in which the partners jointly decided on objectives and activities.One key decision during the formation phase was to explicitly exclude commercial activities from the partnership, such as the sale of insulin or the promotion of Novo Nordisk’s products. Specifically, the partners agreed that any commercial supply relations between Novo Nordisk and the ICRC needed to be handled through a formal, separate tender process. Novo Nordisksubsequently won the tender and, thus, entered into a two-year agreement to supply about 500,000 vials (annual forecast) of human insulin to the ICRC (also serving Médecins sans Frontièresand the DRC). This agreement was based on special pricing principles offered under Novo Nordisk’s Access to Insulin Commitment to humanitarian organizations and low- and middle-income countries. The agreement formally fell outside the scope of P4C.29 Instead, P4C was designed to explicitly focus on capacity building around NCD care in humanitarian-crisis settings.The decision to exclude commercial activities paved the way for the team of representatives from Novo Nordisk, the ICRC and the DRC to begin drafting a Memorandum of Understanding.In the second half of 2017, discussions intensified and focused on the eventual composition of the partnership, its aims and objectives, the roles and responsibilities of each partner, and its geographical scope. In particular, the partners explored where and how they could focus their initial efforts on improving NCD care in a specific humanitarian context. Lebanon, South Sudan, Iraq, Mali, Myanmar, Bangladesh and Syria were all considered.30 Another point of discussion was how to present the case for the partnership to the highest echelons at Novo Nordisk, as the partnership would need approval from executive management and would involve a substantial financial contribution. Various arguments were made. The main arguments related to the positive health impact of the partnership on diabetes care for people in crisis settings, and the potential of the partnership to later inform the health interventions of other humanitarian organizations. Another line of argumentation related to the visibility and reputational value of being a corporate partner of the ICRC, and being seen as a frontrunner in the field of diabetes care. Finally, the team highlighted the motivational value for Novo Nordisk employees of working for a company that was collaborating with the world’s largest humanitarian organization to improve the lives of some of the most vulnerable people with diabetes.31 In late September 2017, Novo Nordisk’s executive management agreed to allow the company to become a member of the ICRC Corporate Support Group (CSG).32 The CSG consisted of a select group of companies that served as official partners to the ICRC and that were allowed to publicly advertise their associations with the Red Cross. Novo Nordisk’s executive management also gave the green light for the partnership itself. This led to the signing of a three-year tripartite partnership agreement on 1 December 2017. The partnership was formally launched at a joint event on 18 April 2018 held on the premises of the Danish Ministry of Foreign Affairs.The collective vision behind the partnership was that all people living with NCDs in humanitarian-crisis contexts should have access to the care they needed regardless of their location. The partners formulated three objectives for P4C to achieve over a period of three years:

  1. To improve access to context-appropriate prevention and care for people affected by diabetes and hypertension in humanitarian settings;
  2. To gather data and evidence on prevention and care in relation to diabetes and hypertension in humanitarian crises, and share it with other actors; and
  3. To explore new ways of partnering for collective impact and inspire others to form multi-stakeholder partnerships to achieve the UN’s Sustainable Development Goals.

To these ends, Novo Nordisk agreed to make annual financial contributions to the ICRC and the DRC for the duration of the partnership. These financial contributions were earmarked for the ICRC’s general health activities, and the DRC’s activities related to NCD prevention and care in crisis contexts. The partners also committed to jointly develop projects and activities for the management, prevention and treatment of diabetes and hypertension in humanitarian settings on the ground. Finally, Novo Nordisk agreed to share relevant expertise in cold-chain management for the delivery of insulin as well as training and education materials (e.g., patient-education materials). Novo Nordisk would not deliver any insulin products as part of P4C nor would any of the parties promote Novo Nordisk’s products in communications resulting from the partnership, including communication with patients and health officials. The ICRC and the DRC committed to leverage their knowledge and expertise of humanitarian operations and response, facilitate access to vulnerable populations, and explore innovation and collaborative approaches, tools and processes.33

27 Interview by the case authors, 14 August 2020.
28 Email correspondence among the partners.
29 Email correspondence between ICRC and Novo Nordisk.
30 Email correspondence between IRCR, DRC and Novo Nordisk, 7 September 2017.
31 Email correspondence between Novo Nordisk and ICRC, 24 October 2017.
32 Email correspondence between Novo Nordisk and ICRC, 28 September 2017.
33 Partnership agreement, Novo Nordisk, the DRC and the ICRC.

ENTERING UNEXPLORED TERRITORY

All three signatories sensed that they had entered unexplored territory. Novo Nordisk, the ICRC and the DRC had committed to collaborating intensely and on equal footing. However, all three partners realized that the drawn-out, three-year process that had led to the formation of the partnership was only the beginning and that the truly complicated parts of partnering were most likely yet to come. While the impressive visuals that would form a central part of the partnership’s advocacy and communication strategy had already been developed, the team was still in the process of fully defining what would be done and where in operational terms. How could it ensure that the partnership would deliver on its promise? How could it ensure equal benefits, not least for the people the partnership aimed to serve? Three challenges provided food for thought and led to critical reflection on what the three partners had agreed to do. The first challenge pertained to the effectiveness of experimenting with new ways of working together as private and humanitarian partners. P4C represented an unprecedented commitment by the partners to collaborate on the development of new solutions in humanitarian-crisis contexts.

However, whether, when and how those commitments could be fulfilled were difficult to foresee. As the partnership represented uncharted territory, Novo Nordisk and its humanitarian partners had to develop a completely new roadmap that brought together different needs and priorities. The formation of the partnership had already been an exciting challenge. How could the partners leverage their complementary capacities to improve access to diabetes care for people in need? The partners also anticipated strong scepticism and scrutiny from within the humanitarian sector about the direct role that Novo Nordisk intended to play in the development of humanitarian solutions. The partners needed to find a balance between drawing on each other’s knowledge, values and capacities, and maintaining their own values and ways of working. How could Novo Nordisk be involved without the partners compromising on their humanitarian principles, such as independence? Was it really necessary for Novo Nordisk to be directly involved in projects on the ground? Perhaps an easier and more effective path to reaching people in need would have been a lighter, more traditional form of corporate involvement. For example, should Novo Nordisk have instead simply provided financial and in-kind donations to the DRC and the ICRC? The second challenge related to sustaining internal support for the partnership. As a groundbreaking partnership, P4C was unprecedented in terms of its scope and intent. However, from the beginning, it was clear that the organization and coordination of the partnership would require significant time and human resources. While none of the partners doubted that P4C would generate value in the long run, no concrete activities had been specified by the time the agreement was signed. Would three years be long enough for the partners to realize P4C’s objectives and ambitions? Would the partners be able to sustain the internal enthusiasm and support for the partnership if tangible results took longer to materialize? The third challenge related to ensuring that the ethics of the generated impact could not be called into question. As the partnership aimed to address the needs of some of the most vulnerable people, the partners felt it was particularly important for any interventions and recommendations for new practices coming out of P4C to be evidence based. To this end, the partners decided to involve the London School of Hygiene & Tropical Medicine (the London School) as an academic partner. By partnering with the London School, P4C ensured the inclusion of a research institute that could provide independent scientific evidence and help with needs assessments, intervention design, and the documentation of results and learning. However, structuring the partnership explicitly around academic research would undoubtedly cause further delays, especially because the London School would have to rely heavily on local research partners for field research. Would the decision to include so many partners hamper P4C in realizing its ambitions? Had the partners been right to prioritize transparency and ethics over more immediate impact? Were there other ways to limit and address ethical concerns?

LOOKING BACK, LOOKING FORWARD

The rising number of humanitarian crises around the world, and their increasing duration and complexity called for new and innovative ways to provide humanitarian assistance. As the Red Cross organizations acknowledged, one way to arrive at such solutions was to include non-conventional partners in humanitarian initiatives. On paper, at least, increased collaboration between businesses and humanitarian organizations—such as strategic partnerships—had the potential to ensure continued financial and non-financial support for humanitarian operations. Such collaboration was also expected to stimulate the development of innovative solutions in a sector that needed to thoroughly consider ethical implications when adopting new modes of working.

For truly innovative solutions to arise, business-humanitarian partnerships had to bring together organizations with distinctly complementary competencies. However, it was not always easy to make such partnerships work, as reflected in the Philips Foundation’s decision to discontinue its partnership with UNICEF. Could business-humanitarian partnerships work? If so, what would it take? Were partnerships the best way for companies to support the work of humanitarian organizations? Should companies stick to offering financial and in-kind donations to support humanitarian assistance, and leave the design and implementation of interventions to humanitarian organizations, as some in the humanitarian community argued? While P4C involved highly reputed and skilful partners, these questions were on the minds of many of the partnership’s observers.

Exhibit 1:

Novo Nordisk’s share structure (as of 3 November 2020)

Source: https://www.novonordisk.com/investors/share-information/share-and-ownership-structure.html

Exhibit 2:

The Fundamental Principles of the International Red Cross and Red Crescent Movement

Source: Based on the Fundamental Principles of the International Red Cross and the Red Crescent Movement (see: https://www.icrc.org/en/fundamental-principles).

Exhibit 3:

Division of roles and responsibilities in “Partnering for Change”