Book Review

Public–Private Partnerships for Public Health

N Engl J Med 2002; 347:1807-1808November 28, 2002

Article

Public–Private Partnerships for Public Health
(Harvard Series on Population and International Health.) Edited by Michael R. Reich. 205 pp. Cambridge, Mass., Harvard Center for Population and Development Studies, 2002. (Distributed by Harvard University Press.) $15. ISBN: 0-674-00865-0

Public–private partnerships for health have grown rapidly in response to the perceived failure of the health systems of developing countries to address major health problems and the perceived failure of the private market to produce needed vaccines and medicines for neglected diseases such as malaria and tuberculosis. There are over 75 public–private partnerships for health, 60 percent of which have been established within the past five years (Initiative on Public–Private Partnerships for Health, available at http://www.ippph.org).

Public–Private Partnerships for Public Health is a collection of seven papers from an April 2000 workshop organized by Michael Reich of the Harvard School of Public Health and the Global Health Council. Reich defines a public–private partnership as a partnership that involves at least one private for-profit organization and at least one public or not-for-profit organization; aims to create social value, generally for disadvantaged populations; and shares both efforts and benefits among partners. He argues, “Partnerships can produce innovative strategies and positive consequences for well-defined public health goals, and they can create powerful mechanisms for addressing difficult problems by leveraging the ideas, resources, and expertise of different partners.” What impact can public–private partnerships for health have on health care development and improved health outcomes? Addressing the ethics of public–private partnerships, Marc J. Roberts and colleagues make the case that “global pharmaceutical and medical device companies have a special responsibility to the sick poor — especially in poor countries.” Case studies covering periods of 8 to 10 years trace the achievements of public–private partnerships developed to control onchocerciasis, or “river blindness” (Laura Frost and colleagues), to combat trachoma-induced blindness (Diana Barrett and colleagues), to introduce new childhood vaccines (William Muraskin), and to combat specific tropical diseases (Adetokunbo O. Lucas). These case studies provide rich insights into the potential impact, dynamics, and challenges of public–private partnerships for health.

The partnership of Merck and the Task Force for Child Survival and Development (formed in 1984 with the World Health Organization [WHO], the United Nations Children's Fund, the World Bank, the United Nations Development Programme, and the Rockefeller Foundation) to combat onchocerciasis is one of the oldest partnerships. Each year Merck donates 30 million to 40 million treatments of its drug, ivermectin (Mectizan). As of 1998, the distribution of ivermectin, combined with control of the black-fly vector, had eliminated infection in up to 1.5 million people, prevented an estimated 200,000 cases of blindness, and freed 25 million hectares of land for human use. In another example, the International Trachoma Initiative, involving the Edna McConnell Clark Foundation and Pfizer, reported in 2000 that in just over one year, pilot projects in Morocco and Tanzania had reduced the prevalence of trachoma by 50 percent.

What is required for a successful partnership? Reich and his collaborators are strongest in their analysis of the dynamics involved in building and sustaining partnerships. Certain features are common to nearly all the long-term partnerships described in the case studies: mutual respect and trust among the partners; leadership and strong personal relations; clear and realistic goals; and a practical recognition of each partner's operating conditions. Key requirements for building mutual respect are that public-sector partners move beyond the view that “profit and public health are incompatible” and that private-sector partners put to rest the notion that the public sector consists only of “entrenched and inefficient bureaucrats.”

Examples of strong leaders who have had important roles in building partnerships include William Foege, a key figure in smallpox eradication and former director of the Centers for Disease Control and Prevention, who had a central role in the ivermectin program; Michael Bailin, president of the Edna McConnell Clark Foundation, whose entrepreneurial approach to “philanthropic investment” made the International Trachoma Initiative possible; Jacques-François Martin, a profoundly committed vaccine and pharmaceutical executive, who worked passionately to establish effective partnerships for the development and distribution of vaccines; and Gro Harlem Brundtland, WHO director-general, who has actively supported the growth of international partnerships.

The story of the Children's Vaccine Initiative, a partnership established to develop new and improved vaccines, illustrates vividly what happens when the necessary conditions for partnership are lacking. Muraskin tracks the Children's Vaccine Initiative from its creation in 1990 through its dismantling in 1999 to the launch of the follow-on partnership, Global Alliance for Vaccines and Immunization. Development agencies saw the focus on vaccine development as a “technological fix” that was unresponsive to the real needs of developing countries, industry leaders were frustrated by public health officials they viewed as naive about the realities of private initiative, and international organizations seemed unable to move beyond bureaucratic and institutional constraints. Whatever shortcomings remain to be addressed, the creation of the Global Alliance for Vaccines and Immunization suggests that even highly contentious dynamics can be overcome when mutual respect, leadership, clear goals, and logistical practicalities coalesce.

What are the potential adverse effects of public–private partnerships? It is on this question that readers will find Public–Private Partnerships for Public Health most lacking. Kent Buse and Gill Walt describe both the potential benefits and the potential negative influences of partnerships for health. The authors' concerns about the role of WHO in public–private partnerships would not be shared by the many people who see these partnerships as leading to substantive improvements in health outcomes. But the authors do express the frequently voiced concerns that such partnerships may involve less accountable and less democratic governance structures, focus on relatively narrow problems and solutions, give too little attention to the strengthening of health systems, and distract public-sector partners from other high-priority obligations.

Aside from these observations by Buse and Walt, the book says too little about the circumstances under which public–private partnerships for health may not be appropriate or about the potential adverse effects associated with such partnerships. Do public-sector organizations become less willing to speak on issues contrary to the interests of their corporate partners? Do corporate participants sometimes use partnerships for market penetration or to influence international and national policies? Is there an adverse “image transfer” when governments, international organizations, or nongovernment organizations establish partnerships with companies that also engage in troubling practices involving pricing, promotion, and efforts to limit competition?

With regard to potential conflicts of interest, Reich clearly lists the organizations that provided financial support for the workshop and the book. Three of the four are private companies involved in public–private partnerships for health, though it is indicated that they played no part in the selection or content of the papers.

Public–Private Partnerships for Public Health provides a solid overview of the partnership process and of the potential impact of public–private partnerships for health. Readers will need to look further to understand the caution with which many in the public health community view such partnerships. Nonetheless, this book will be valuable for anyone who wants to understand how partnerships are trying to bring new creativity, greater visibility, and often increased resources to a range of public health challenges.

Jonathan D. Quick, M.D., M.P.H.
World Health Organization, CH-1211 Geneva, Switzerland
quickj@who.int