Elsevier

Social Science & Medicine

Volume 64, Issue 2, January 2007, Pages 259-271
Social Science & Medicine

Seven habits of highly effective global public–private health partnerships: Practice and potential

https://doi.org/10.1016/j.socscimed.2006.09.001Get rights and content

Abstract

Global public–private health partnerships (GHPs) have become an established mechanism of global health governance. Sufficient evaluations have now been conducted to justify an assessment of their strengths and weaknesses. This paper outlines seven contributions made by GHPs to tackling diseases of poverty. It then identifies seven habits many GHPs practice that result in sub-optimal performance and negative externalities. These are skewing national priorities by imposing external ones; depriving specific stakeholders a voice in decision-making; inadequate governance practices; misguided assumptions of the efficiency of the public and private sectors; insufficient resources to implement partnership activities and pay for alliance costs; wasting resources through inadequate use of recipient country systems and poor harmonisation; and inappropriate incentives for staff engaging in partnerships. The analysis highlights areas where reforms are desirable and concludes by presenting seven actions that would assist GHPs to adopt better habits which, it is hoped, would make them highly effective and bring about better health in the developing world.

Introduction

The decade spanning the turn of the Millennium marked a crossroads in international health. It witnessed, on one hand, the HIV/AIDS pandemic and resurgence of TB and malaria and, on the other, dramatic increases in financial commitments to fight these diseases and a fundamentally new approach to tackling them through public–private partnerships. These partnerships precipitated a watershed by bringing new actors, resources, business models and a sense of urgency to addressing neglected diseases.

The term ‘public–private partnership’ is a difficult one. Arriving at an agreed definition in the health sector has proven problematic. Here we use the term to describe relatively institutionalised initiatives, established to address global health problems, in which public and for-profit private sector organisations have a voice in collective decision-making. Such partnerships vary across a range of variables including their functional aims, the size of their secretariats and budgets, their governing arrangements, and their performance. Yet it is their innovative approach to joint decision-making among multiple partners from the public and private sectors which make them a unique unit of analysis which we call global health partnerships (GHPs) (Buse, 2004a).

This analysis is based on research projects in which the authors have been involved over the past 5 years (Buse, 2003; Caines & Buse (2004), Caines et al. (2004); Caines et al., 2004; Buse & Harmer, 2004; Harmer, 2005). It also draws on interviews with officials associated with GHPs, advisory work conducted by the authors for the Secretariats and Boards of GHPs, data from GHP Internet sites, as well as published and unpublished literature. For this study, we systematically reviewed the governance structures of over 100 initiatives. Our sample consists of all the initiatives which report involving representatives from both the public and private sectors on decision-making bodies. Thus our sample is representative of a particular form of partnership rather than representative of all partnerships. Given our selection criteria, important partnerships such as the Drugs for Neglected Diseases initiative and the Green Light Committee are excluded. That our sample size is so small is in itself a surprising finding. In contrast to the widely espoused number of 80–100 GHPs, we identify just 23 as satisfying our criteria (Table 1).

Our paper begins by outlining seven important contributions which GHPs make to international health. Subsequently we present seven ‘unhealthy’ habits which GHPs commonly practice. We conclude by recommending seven corresponding reforms to create ‘highly effective’ partnerships able to realise their potential to bring about better health in the developing world.

Section snippets

GHPs: the value added to international health

GHPs have been remarkably speedy out of the starting blocks, particularly when compared with the time it has taken to establish other international initiatives (Bezanson, 2005). In addition, GHPs have made seven impressive contributions to efforts to tackle neglected diseases. These are:

  • getting specific health issues onto national and international agendas;

  • mobilising additional funds for these issues;

  • stimulating research and development (R&D);

  • improving access to cost-effective health-care

Seven unhealthy habits

Despite their remarkable achievements, the broader picture is one in which these same GHPs commonly practice seven unhealthy habits. We argue that GHPs skew national priorities of recipient countries by imposing those of donor partners; deprive specific stakeholders a voice in decision-making; demonstrate inadequate use of critical governance procedures; fail to compare the costs and benefits of public vs. private approaches; fail to be sufficiently resourced to implement activities and pay for

Unhealthy habit 1: GHP alignment: ‘out of sync’

The principle of alignment is recognised internationally as a cornerstone of effective development cooperation. The 2005 Paris Declaration on Aid Effectiveness, for example, calls for ‘increasing alignment of aid with partner countries’ priorities, systems and procedures’. In particular, it commits donors to align their assistance with recipient countries’ national priorities, provide aid through existing government channels, and switch from ‘project aid’ to ‘general budget,’ ‘sector budget,’

Unhealthy habit 2: GHPs are not representative of their stakeholders

One habit prevalent among GHPs is their failure to provide legitimate stakeholders a voice in decision-making on governing bodies. Table 1 reveals that constituencies from low- and lower-middle-income countries (LMICs) are under-represented on governing bodies, with an average of just 17% of the membership across our sample. Non-government organisations (NGO) are least represented (5%) whilst the corporate sector has the greatest representation (23%).

Table 1 merits further comment. First, the

Unhealthy habit 3: poor governance

Many GHPs have slipped into poor governance habits including: failure to clearly specify partners’ roles and responsibilities; inadequate performance monitoring; insufficient oversight of corporate partner selection and management of conflict of interest; and a lack of transparency in decision-making.

Most GHP evaluations comment on the lack of specificity on partner roles and responsibilities. Lack of role clarity was found in reviews of MIM (Bockarie, Bond, & Mutambu, 2002), the Global Polio

Unhealthy habit 4: vilification of the public sector

Few, if any, studies of GHPs draw attention to the role that GHPs should play in engendering a sense of global public responsibility. There is insufficient space here for an historical account of the rise of GHPs (Harmer, 2005) but one important feature is the rise of the World Bank as an increasingly influential actor in setting the agenda for global health policy, particularly in its desire to involve the private sector in health finance and delivery. As the Bank's influence increased, so

Unhealthy habit 5: inadequate finance

The fifth habit focuses on the tendency of GHPs to lack the necessary resources to carry out planned activities or to finance the true costs of extensive consultation required for partnership.

Research draws attention to the funding crisis plaguing many GHPs. As a result, there is a danger that some GHPs will simply collapse because of lack of financial support. To be clear, it is the individual partners that are being miserly, not the GHP itself. Yet partners do not seem to reflect their

Unhealthy habit 6: poor harmonization

GHPs have failed to harmonise their procedures and practices with one another and with other donors leading to duplication and waste. Studies have found many examples of duplication in planning, project-specific M&E, missions and financial management, and parallel systems for health service delivery (e.g., drug procurement and distribution) among GHPs (Caines & Lush, 2004; Lele et al., 2005; McKinsey, 2005; Walt et al., 2004).

The Global Fund has attracted more attention than other GHPs for poor

Unhealthy habit 7: inadequate incentives to partner facing staff

The final habit arises from the organisational commitment and loyalty employers demand of their staff—often explicitly forbidding staff to have outside interests, particularly if there may be apparent, potential or real conflicts of interests. Yet partnership is about engaging in external relationships and investing in them a variety of commitments. The tensions arising out of such competing loyalties manifest in different ways.

Secretariat staff in ‘hosted partnerships’ are often under intense

Conclusions: seven habits of highly effective partnerships

We have argued that many GHPs, either by commission or omission, have acquired seven unhealthy habits, the consequence of which is that they risk languishin in perpetual sub-optimal performance. To encourage the adoption of better habits, we conclude with a summary of seven actions that GHPs should take.

First, GHPs need humility to embrace the aid modalities of the Paris agenda (national ownership, alignment and harmonisation) so as to integrate their efforts with national planning processes

Acknowledgements

Thanks to Gill Walt for comments on the paper and to all the global public–private health partnerships staff who have shared generously of their time and resources over the years.

References (52)

  • A. Creese et al.

    Cost-effectiveness of HIV/AIDS interventions in Africa: A systematic review of the evidence

    Lancet

    (2002)
  • Bezanson, K.A., (2005). Replenishing the global fund: An independent assessment. The Global Fund....
  • Bockarie, M., Bond, E., & Mutambu, S. (2002). Review of the multilateral initiative on malaria. Final Report,...
  • K. Buse

    Governing partnership—A comparative analysis of the organizational and managerial arrangements of 18 global public–private health partnerships

    (2003)
  • K. Buse et al.

    Global public-private partnerships: Part I – a new development in health?

    Bulletin of the World Health Organisation

    (2000)
  • K. Buse et al.

    Global public-private health partnerships: Part II – what are the issues for global governance?

    Bulletin of the World Health Organisation

    (2000)
  • K. Buse

    Global health partnerships: Mapping a shifting terrain

    (2004)
  • K. Buse

    Global health partnerships: Improving their impact through governance

    (2004)
  • K. Buse

    Governing public–private infectious disease partnerships

    Brown Journal of World Affairs

    (2004)
  • K. Buse et al.

    Power to the partners? The politics of public–private health partnerships

    Development

    (2004)
  • K. Caines

    High level forum on the health MDGs working group on global health initiatives and partnerships: 25–26 April 2005

    (2005)
  • K. Caines et al.

    Independent external evaluation of the global stop TB partnership

    (2003)
  • K. Caines et al.

    Global health partnerships: A selective review of the literature

    (2004)
  • K. Caines et al.

    Assessing the impact of global health partnerships

    (2004)
  • K. Caines et al.

    Impact of public–private partnerships addressing access to pharmaceuticals in selected low and middle income countries. A synthesis report from studies in Botswana, Sri Lanka, Uganda and Zambia

    (2004)
  • Caines, K., & N’jie, H. (2002). Report of the external review of the functions and interactions of the GAVI working...
  • C. Carlson

    Assessing the impact of global health partnerships: Country case study report. Report prepared for UK Department for International Development

    (2004)
  • Commitment to development index 2005

    (2005)
  • Casper, T. (2004). Updated discussion paper on the core business model of a mature global fund. Ninth Board Meeting of...
  • G. Chee et al.

    Evaluation of GAVI Immunization Services Support Funding

    (2004)
  • N. Druce et al.

    The determinants of effectiveness: Partnerships that deliver review of the GHP and ‘business’ literature

    (2004)
  • A. Fairlamb et al.

    Independent review of medicines for malaria venture

    (2005)
  • R. Feachem

    Final report of the external evaluation of the roll back malaria. achieving impact: Roll back malaria in the next phase

    (2002)
  • L. Frost et al.

    A partnership for Ivermectin: Social world and boundary objects

  • GAIN (2005). Factsheet: What GAIN requires. 〈http://www.gainhealth.org/pdf/strategic_plan/13_WHAT_GAIN_REQUIRES.pdf...
  • GAVI (2005). Fact sheet 〈http://www.vaccinealliance.org/resources/FS_Donor_en_Feb2005.pdf...
  • Cited by (0)

    With acknowledgement to Steven Covey.

    View full text