Kent Buse

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

The proliferation of public-private partnerships is rapidly reconfiguring the international health landscape. This article (part I of two on the subject) traces the changing nature of partnership, and discusses the definitional and conceptual ambiguities surrounding the term. After defining global public-private partnerships (GPPPs) for health development, we analyse the factors which have led to the convergence of public and private actors and discuss the consequences of the trend toward partnership between UN agencies (including the World Bank) and commercial entities in the health sector. Generic factors such as globalization and disillusionment with the UN, and factors specific to the health sector, such as market failure in product development for orphan diseases, are examined. Reviewed are the interests, policies, practices and concerns of the UN, the private-for-profit sector, bilateral organizations, and governments of low-income countries with respect to public-private partnership. While GPPPs bring much needed resources to problems of international health, we highlight concerns regarding this new organizational format. Part II, which will be published in the May issue of the Bulletin, presents a conceptual framework for analysing health GPPPs and explores the issues raised.

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

This is the second of a two-part review of global public-private partnerships (GPPPs) for health development. Part I was published in the April issue of the Bulletin (Vol. 78, No. 4). The recent emergence of GPPPs is rapidly reconfiguring the international health landscape. While most multilateral and bilateral agencies are currently grappling with how to proceed, there is little information in the public domain concerning how individual partnerships work and to date very little consideration of the many implications of this trend. This paper differentiates between product-based, product development-based and issues/systems-based GPPPs and describes a number of examples of each type in the health sector. The benefits of these initiatives, not least the major resources which they harness for specific health problems, are identified. The final section of the paper explores the implications and dilemmas posed by GPPPs. It discusses whether or not shared goals can transcend conflicting values and mandates and how governance of partnership arrangements may transform and undermine certain attributes of multilateral organizations. The paper concludes that the current climate of goodwill between public and private sectors offers an opportunity that should not be missed: it can be used not only to foster new partnership but to ensure that partnership is truly in the interests of international public health.

Public-private health partnerships: a strategy for WHO

Following early success with a number of high-profile partnerships, WHO is increasingly working with the private for-profit sector. In so doing, the organization finds itself in the maelstrom of a vibrant debate on the roles of public, civic, and commercial entities in society and on the appropriate modes of interaction among them. This paper examines WHOs involvement with the commercial sector, particularly in partnerships. WHOs approach to this sector is outlined and the criticisms levelled at public-private partnerships are reviewed. An indication is given of the steps recently taken by WHO to confront the concerns that have been expressed. The paper argues that partnership between WHO and the commercial sector is inevitable and that it presents considerable opportunities, but also significant risks, for the organization and for public health. A strategy is proposed for directing the debate on issues critical to WHO and its role in the promotion and protection of public health.

Defeating AIDS—advancing global health

After more than a decade of major achievements the AIDS response is at a crucial juncture both in terms of its immediate trajectory and its sustainability as well as its place in the new global health and development agendas. In May 2013 the UNAIDS-Lancet Commission -- a diverse group of experts in HIV health and development young people people living with HIV and affected communities activists and political leaders -- was established to investigate how the AIDS response could evolve in a new era of sustainable development. The UNAIDS-Lancet Commission has come together at a moment when the lessons of the AIDS response including its whole-of-society perspective can be informative and even transformational for other spheres of global health. The path to ending AIDS as a public health threat by 2030 as set out in this report should be a major part of the post-2015 development agenda. On the basis of our analysis and discussion we make the following seven key recommendations: Urgently escalate AIDS efforts get serious about HIV prevention and continue expanding access to treatment; Mobilise more resources spend efficiently and emphasise sustainability; Demand robust accountability transparency and better data; Forge new paths to uphold human rights and address criminalisation stigma and discrimination; Reinforce and renew leadership and engagement of people living with HIV; Invest in research and innovation in all facets of the AIDS response; and Promote more inclusive coherent and accountable governance for AIDS and health. In conclusion the question is no longer whether the fight against AIDS can be won; the only questions are: will it be won -- and when? The answers to these questions will eventually depend on the decisions made by leaders and institutions at all different levels in all sectors and parts of society and on the personal choices people make in their private lives. (Excerpts)

An unruly mélange? Coordinating external resources to the health sector: A review

The past two decades have witnessed an upsurge in the number of external agencies involved in the health sectors of developing countries. Concomitantly, there has been an increase in the volume of resources transferred through multilateral, bilateral and non-governmental organizations to these health systems. Notwithstanding the beneficial impact of increased resources, recipients and donors are increasingly concerned about the effects of this trend. This is particularly pertinent where the effort lacks adequate coordination. Recipients despair of an unruly mélange of external ideas and initiatives, that too often results in project proliferation and duplication, unrealistic demands, and ultimately a loss of control over the health development process. Donors on the contrary, are concerned about aid efficiency and effectiveness, two areas it is assumed will gain from increased attention to coordination. Both recipients and donors are looking for ways of better managing the aid relationship. Although there has been considerable experience with coordination strategies, most writing has considered external assistance in general, rather than the health sector in particular. The literature is striking in its bias towards the needs and perspectives of the donor community. There has been little analysis of the manner in which recipient ministries of health manage donors and the influx of resources. This review begins to fill this gap. Its focus is country-level, where most direct gains from coordination are to be reaped. The paper begins with an enumeration of the many and diverse trends which have raised the salience of aid coordination. A definition of coordination, a term used ambiguously in the existing literature, is then developed and the principles of aid coordination outlined. Finally, attention is directed to the initiatives of recipients and donors to improve the coordination of health sector aid.

Gender and global health: evidence, policy, and inconvenient truths

In this article the authors survey the evidence for the role of gender in health status analyze responses to gender by key global health actors and propose strategies for mainstreaming gender-related evidence into policies and programs. Using the WHO definition of gender the article attempts to disentangle and quantify the exact contributions that sex and gender make to health status which often interact with other social determinants of health. The authors analyzed the recent Global Burden of Disease (GBD) from a gender perspective. Data from this study are intended to help policy makers to set priorities and allocate resources according to population health needs. Evidence shows that gender – a social construct – has a substantial effect on health behaviors access to health care and health system responses. The tendency to underplay or misunderstand the role of gender or to equate the gender dimensions of health solely with the specific health needs of women has led to a failure to address the evidence of gendered determinants that affect and drive the burden of ill health of both men and women.

Health in the sustainable development goals: ready for a paradigm shift?

The Millennium Development Goals (MDGs) galvanized attention, resources and accountability on a small number of health concerns of low- and middle-income countries with unprecedented results. The international community is presently developing a set of Sustainable Development Goals as the successor framework to the MDGs. This review examines the evidence base for the current health-related proposals in relation to disease burden and the technical and political feasibility of interventions to achieve the targets. In contrast to the MDGs, the proposed health agenda aspires to be universally applicable to all countries and is appropriately broad in encompassing both communicable and non-communicable diseases as well as emerging burdens from, among other things, road traffic accidents and pollution.We argue that success in realizing the agenda requires a paradigm shift in the way we address global health to surmount five challenges: 1) ensuring leadership for intersectoral coherence and coordination on the structural (including social, economic, political and legal) drivers of health; 2) shifting the focus from treatment to prevention through locally-led, politically-smart approaches to a far broader agenda; 3) identifying effective means to tackle the commercial determinants of ill-health; 4) further integrating rights-based approaches; and 5) enhancing civic engagement and ensuring accountability. We are concerned that neither the international community nor the global health community truly appreciates the extent of the shift required to implement this health agenda which is a critical determinant of sustainable development.

Addressing the theoretical, practical and ethical challenges inherent in prospective health policy analysis

As a function of the inherently political nature of health policy, there have long been calls for, as well as guidance on, analysis of its political dimensions to inform practice. Yet there are few accounts in the literature of systematic attention to real-time documentation and analysis of political-economy factors and feedback to engender reform. The dearth of such prospective policy analysis is perhaps understandable given the many intrinsic difficulties in such an enterprise. This paper provides an outline approach of how researchers might work together with advocacy coalitions (or other political actors) to document and analyse the efforts of such coalitions to use policy analysis to influence the policy processes-agenda setting, policy formulation and policy implementation-in which they engage. In so doing, it identifies challenges based on reviews of the theoretical, methodological and empirical literature as well as the experience of the author. The aim of the paper is to generate debate to assist in resolving the myriad challenges inherent in prospective policy analysis. The paper responds to appeals for political research which addresses the problems confronting political actors so as to guide future action-research for evidence-informed, pro-poor health policy.

Aid coordination for health sector reform: a conceptual framework for analysis and assessment.

Recent widespread interest in health sector policy and institutional reform in lower income countries has coincided with heightened concern for aid coordination. Because the health budgets of many low income countries are highly aid dependent, donors are strongly placed to make aid conditional on health care reforms. However, given the growing number and heterogeneity of multilateral, bilateral and international non-governmental donors operating in many of these countries, there is concern that if external efforts are not coordinated, the aims of health care reform--namely improving efficiency, effectiveness and equity--will not be met. Evidence is mounting that without effective coordination arrangements, donors may weaken rather than improve fragile health systems, undermining attempts to reform those systems. This paper traces the factors fuelling current interest in coordination, in particular with reference to its contribution to the goals of health sector reform. Aid coordination is defined and its principles elaborated. A framework is developed by which to assess the variety of coordination mechanisms which are evolving at the county level. In light of this framework, a case is made for greater and more critical analysis of aid coordination arrangements. The paper concludes that if health sector reform is to be successful in low income countries, current enthusiasm for coordination needs to be harnessed. The framework offered here provides a way of assessing the variety of coordination mechanisms currently proliferating, which could be used to enhance health sector reform.

The World Bank and global cooperation in health: the case of Bangladesh

The final quarter of the 20th century saw a profound change in international health cooperation. The World Bank emerged and consolidated its position as the leading external financier of health-sector activities in countries of low and middle income. As a result of its resources, philosophy, and legitimacy, the World Bank leveraged fundamental reform of the health-sector agenda as well as institutional relations at global and national levels. The scope of the Banks involvement, and the nature of its policy thrusts and investment strategy in the sector, are outlined in this paper and illustrated with specific reference to Bangladesh. This backdrop serves to raise four issues and enables us to explore their relevance to global health cooperation in the first quarter of the 21st century.