A growing number of highly diverse new organizations, networks and alliances focusing on discrete and measurable areas of action have superseded the simple division of delivery mechanisms between bilateral and multilateral health agencies.
An increasing number of public-private partnerships (PPPs) are engaged in reducing the disease burden in the poorest countries. There are about 80 global public-private partnerships (GPPPs) in the health sector, differing in terms of legal status, disease focus and area of activity, and ranging from small initiatives for single issues to large institutions for multiple diseases. They may act as channels for the disbursement and management of funding programmes or may directly undertake research and/or health service provision. They are mostly funded through official development assistance (ODA), but, in some cases, they also combine income from philanthropic foundations or business partners. A focus on specific targets and diseases brings greater efficiency and makes it possible to transfer lessons and approaches from one country to another. However, this ‘vertical’ programme approach also creates problems for the recipient country, because it does not readily respond to local conditions and priorities, it creates high coordination costs and may divert resources away from other elements of the health and care system.
In the health sector, public-private partnerships play a role, particularly in three contexts:
- In the provision of health-related services in the European countries themselves
- As a mechanism of development cooperation in bilateral relationships
- As a global means of tackling health-related problems that transcend national boundaries
PPPs consist of two basic types of actors – state and non-state actors – that can be further differentiated by their level of activity and their respective sector. The main state actors represented in global public-private partnerships come from the national level (governments, bilateral agencies), the local level (administrative bodies, local authorities) and the international level (international organizations). The non-state actors can be further divided into those from the private sector (for-profit companies, business associations, foundations) and those from the civil society sector (grass-roots organizations, national NGOs, international NGOs).
In global health, PPPs started to gain importance at the beginning of the 1990s. In a phase where the UN System was increasingly criticized for being bureaucratic and ineffective, and where nation states were losing their regulatory authority due to globalization processes, cooperation with non-state actors in the form of GPPPs seemed a promising way forward to address issues that could not be resolved in the national context or by single actors alone. This specific type of partnership can be defined as a “collaborative relationship which transcends national boundaries and brings together at least three parties, among them a corporation (and/or industry association) and an intergovernmental organisation, so as to achieve a shared health-creating goal on the basis of a mutually agreed division of labour”.
In order to structure the complex field of GPPPs in health and other areas, a number of typologies have been developed, including the following three.
On way of mapping different types of partnerships is by their legal status. Are they legally independent entities or are they hosted inside an existing organization and, if so, what type of organization? Starting with these criteria, Widdus (2002) distinguishes between four types of GPPP:
- those with a public sector host (for example, national, bilateral or multinational institution)
- those with a commercial host (for example, pharmaceutical, private medical, or non-health-related for-profit company)
- those with a non-profit host (for example, non-governmental organization, educational and research institution, or civil society group)
- those which operate independently from any host organization with their own legal authority. While approximately 40 per cent of all GPPPs have a public sector host, non-profit and independent hosts each account for roughly 25 per cent, while commercial hosts are the least common, accounting for about 10 per cent.
A second way of categorizing GPPPs is by their disease focus. Do they cover mainly the most prominent infectious diseases like HIV and AIDS, tuberculosis and malaria, or are they targeted at the so-called neglected diseases (defined as “diseases affecting principally poor people in poor countries, for which health interventions – and research and development – are regarded as inadequate to the need”)? Do they concentrate on communicable or non-communicable diseases or do they have no specific disease focus at all but focus on health system development or other issues? It can be observed that GPPPs focus mostly on communicable diseases (with AIDS, tuberculosis and malaria alone accounting for nearly half of all GPPPs) and increasingly also on neglected diseases (approximately 20 per cent). Non-communicable diseases, reproductive health and health system development represent the focus of only about 10 per cent of all GPPPs.
A third typology, developed by the UK’s Department for International Development (DFID), is based on the area of activity and distinguishes between partnerships active in research and development (product discovery, development of new diagnostics, drugs and vaccines), GPPPs in the area of technical assistance and service support (service access, provision of discounted or donated drugs ), GPPPs that concentrate on advocacy activities at global and national level (including resource mobilization), and partnerships in the area of financing (provision of funds for specific disease programmes). An analysis of health GPPPs applying this typology shows that the last type of GPPP is relatively rare (with The Global Fund to fight AIDS, Tuberculosis and Malaria, and the Global Alliance for Vaccines and Immunisation (GAVI) being the most important actors in this category), while advocacy is a central activity of approximately 20 per cent of all GPPPs (for example, the Roll Back Malaria (RBM) Partnership, the Stop TB Partnership, the Global Campaign for Microbicides (GCM)) and the vast majority of GPPPs concentrate on research and development (for example, International AIDS Vaccine Initiative (IAVI), Drugs for Neglected Diseases Initiative (DNDi) and Medicines for Malaria Venture (MMV)) or service support (for example, ActionAid International (AAI), the Coartem Partnership and NetMark Plus).
The different participants interact in GPPPs on a voluntarily basis in order to pursue common goals and shared objectives. They aim to share risks and benefits, using the comparative advantages of the different types of actors, and pool their specific resources (for example, financial resources, technological know-how, human resources, management capacities, public reputation, advocacy skills). In order to coordinate the activities of the various actors, GPPPs tend to follow a network approach, with horizontal interactions and lean administrative structures. Most GPPPs have some kind of executive board for decision-making purposes, accountable to the partners of the GPPP, and a broader stakeholder forum that enables the different constituencies of the partnership to participate and express their views. GPPPs are expected to combine the positive aspects of public regulation (binding decisions) and private regulation (autonomy), while avoiding their negative aspects (lack of flexibility, negative externalities). It remains to be seen, however, how the potential of state and non-state actors can be combined in practice. This depends on the governance structure and network management, while factors like mutual trust, learning processes and communication structures are important.
Critics argue that policy-making in and through GPPPs can be associated with a number of problems. Firstly, the inclusion of non-state actors raises questions of legitimacy and accountability. While state actors are legitimized through elections and can be held accountable by mechanisms of democratic control, non-state actors have not been formally legitimized and are only accountable to their members or supporters. This can be considered problematic as it may lead to an undue influence of private interests, a limited legitimacy of the GPPP, and an undermining of public policy-making. Secondly, the large number of GPPPs can cause coordination problems, as most of the partnerships focus on single diseases or activities and aim to produce goal-oriented outputs in their specific area. The sum of these activities, however, does not necessarily result in a coherent policy, but can contribute to fragmented approaches to global health. Thirdly, GPPPs compete with each other and with other actors in global health for scarce resources and influence. The proliferation of GPPPs may lead to a distortion of funding and a further verticalization of health policies.
It is, therefore, important to monitor the performance of GPPPs carefully and to pay more attention to their impact at country level. This requires the development of appropriate systems for monitoring and evaluation and mechanisms of accountability. At global level, a clearer division of labour between the various GPPPs and other actors is necessary in order to avoid a duplication of activities and to improve coordination.