Seven habits of highly effective global public–private health partnerships: Practice and potential☆
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by the authors for the Secretariats and Boards of GHPs, data from GHP Internet sites, as well as published and unpublished literature.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:
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getting specific health issues onto national and international agendas;
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mobilising additional funds for these issues;
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stimulating research and development (R&D);
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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.
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With acknowledgement to Steven Covey.