Contents Introduction ......................................................................................... 2 Are Public-PrivatePartnerships the new panacea? .................................. 3 What are Public-Private Partnerships? ................................................... 3 The evolution of Public-PrivatePartnerships ............................................ 4 Why join a Public-PrivatePartnership? .................................................. 5 Philosophy and basic strategy ............................................................ 7 Lessons learned .................................................................................. 9 Annex 1 Case Studies I Public-PrivatePartnershipto promote handwashing with soap in Central America ............................................................................. It NetMark: Partnershipto increase the use of insecticide-treated materials to prevent malaria................................................................. Ill Partnershipwith condom manufacturers to promote condom use in red light areas in Indonesia .............................................................. IV Partnershipto increase the consumption of iodized salt in Pakistan ........... V PHASE: Clean hands. happy hands. hygiene promotion in schools ........... VI The global alliance for Vaccines and Immunization ................................. References ...........................................................................................20 Introduction Public-private partnerships (PPPs) have evolved an ideological shift which has created a as a result of pressure to ensure quality in facilitating environment for business, providing public services. PPPs pool public and disillusionment with UNefficiency, a recognition private resources, and capitalize on the skills of that the global health agenda is too large for a the respective sectors to improve the delivery of single sector or organization to address on its services. Today, PPPs in the health sector focus own, a realization that the market alone cannot on preventing diseases such as sexually provide solutions, and a growing interest within transmitted infections and malaria, developing the private sector to enhance its involvement in and facilitating accessto vaccinesand drugs, and social issues. improving health service delivery. Whether international or national in scope, PPPschallenge Partnership is now the keyword in PPPs. Early the traditional distinction between the public and PPPs had ad hoc partnership arrangements, private sector, and their perceived aims and which allowed for flexibility. However, as responsibilities. partnerships have become more common, complex, and global in scale, governance and Although a numberof PPPshovebeenestablished constitution have become increasingly important in the public health sector over the past few in keeping initiatives focused. decades, little information is available on the necessary conditions leading to their formation. Thefeatures of a successful PPParetransparency, To address this need, this review has been accountability, a sound governance structure, prepared as a guide to best practices for PPPs and a well-defined leadership. Other factors for in the health sector. It examines the underlying success are a clear understanding of market philosophy of PPPs, their costs, benefits, mechanismsand how they influencethe outcome and impacts, as well as their governance, and overall strategy of the PPf? management, and implementation strategies. While the main focus of health partnerships is to The report draws on the experiences of six case meet public health goals, the possible costs and studies of PPP initiatives, interviews with key benefits need to be carefully studied to evaluate players from the private and public sectors, and their wider socio-economic impact. To do this, six literature. The review offers general lessons of case studies were documented in Annex 1 and principle and process for forming partnerships are referred to throughout the review in relation and effectively managing them. to lessons learned and principles of governance, Fivecontextualshifisin international public health communications,strategy, selectingpartners, and are cited as reasons for the emergence of PPPs: measuring impact. partnerships, this review has been preparedas a guide to best practices for PPPs in the health sector. It examines the underlyingphilosophy of PPPs, their costs, benefits, impact, governance, Public-private partnerships (PPPs) have become management, and implementation strategies. the preferred mechanismfor internationalefforts Lessons and analyses were taken from the 70addressemerging to improve public heqlth over the last decade. experiences of six case studies (Annex I), Joint ventures are being set up between public interviews with key players from the private hr& to health, new and sectors as a result of pressure to and public sectors, and literature. The review Forms ofd o n am ensure quality in public services at a time when offers general lessons of principle and process needed. There is a clear governmental and international development for forming partnerships and effectively budgets are shrinking. In principle, partnerships need to break h q h managingthem. pool resources, capitalizingon the skills of each traditionalboundaries sector. They can benefitcitizensby improvingthe within government standard of health, governments by reducingthe sectors, behvlcnw, investment burden, and industry by increasing profits. Whether international or national in gorsnnenlolond scope, they challenge the traditional view that "To address emerging threats to health, new nongomenia! the aims and responsibilities of the public and forms of actionare needed.There isa clear need organizations, cmd private sector arediscreteandopposed (Buseand to break through traditional boundaries within Walt, 20000). bstween thepublic and governmentsectors, betweengovernmental and nongovernmental organizations, and between heprivatesectors. Although the term itself, "public-private the public and private sectors. Cooperation is Cooperation is partnership," is relatively new, collaborations essential; this requires the creation of new betweengovernmentsand industryhavebeenin essential; his requires partnerships for health, on an equal footing, existence for many decades in different forms, he creation bFnew between the different sectors at all levels such as "privatization," "contracting out," "new of governance in societies" (WHO, 1997 The parherships for heahh, management ideas," and "competition in the Jakarta Charter). public sector." The concept of "partnership" has on an qwl hting, become possible through a change in attitude between the dihrent There can be a wide spectrum of arrangements on the part of policy makers. Commercial betweenthe publicand privatesector to provide sectors at a//levels of suppliers, who were earlier perceivedto be more public services. At one extreme, government governance in societies." interested in profits than in public welfare, are playsthe role of a provider.At the other extreme, now being viewed as useful partners in public services are fully privatized and the role of service. Government officials, who were often The Jakarta Charter, 1997 government is limited to that of a regulator. perceived to be authoritarian and needlessly According to the United Nations Development obstructive, are now being regarded as capable Program (UNDP),the broadestdefinition of PPPs and responsivepartners(SlaterandSaade, 1996). includes agreement frameworks, traditional PPPs in the healthsector are being putto the test contracting, and joint ventures with shared in preventing diseases such as sexually ownership. For the purpose of this review, PPPs transmitted infections and malaria, increasing are defined as the spectrum of possible consumer awareness, and developing and relationshipsbetween public and privateplayers facilitating access to vaccines and drugs. While for the cooperative provision of infrastructure they have the potential to unlock resources and and/or services. Traditional contracting and deliver effective health services, they are not a corporate philanthropy are excluded from this panacea. Widdus (2001) suggests that they definition. should be viewed as social experiments, and as A distinguishing feature of PPPs is that the such, their philosophy, costs, benefits, and wider impact, as well as their governance, parties develop a shared governance structure management, and implementation strategies and decision-making process. They forge an need to be examined. agreementto implementspecifiedactivities and commit resources (i.e., financial, technical, or In the absence of detailed information on the personnel) in order to realize common goals formation, governance, and operations of such such as disease reduction through increased treatment coverageor developmentof avaccine Hygiene and Sanitation Education [PHASE], (BPOG, 2000). Although motivationsmay differ NetMark, GAVI)."Pull" incentivesare offered (i.e., increased market for products versus in some partnerships, such as market decreased disease incidence) between the two guarantees, tax credits, and early sectors, PPPs allow the sectors to work together recommendation for product introduction towardcommonobiectives.Generally PPPsinthe from international agencies (Widdus, 2001). health sector have three objectives: GAVI and NetMark are examples of this type of PPf? 1) To promote those behaviors (i.e., use of bednets, safe sex, handwashing)that reduce Systerns/issues-based partnerships:These the incidence of diseases such as malaria, collaborations can help overcome market AIDS, and diarrhea; failure, tap non-medical private resources, and bring strategic consistency to different 2) To facilitate equitable access to vaccines and approaches to combat a single disease (i.e., treatments; and Roll Back Malaria) (Buse and Walt, 2000b). 3) To improve health service delivery. There are three common modelsof partnership: product-based partnerships, product- Until the late 1970s, governments and development partnerships, and systems/issues- development agencies contracted the private based partnerships. sectorto executelargeinfrastructureprojects, such Producf-based partnerships: These are as railroads,sewers, and rood networks(see Box primarily drug donation programsto increase 1). A clear agreement was drawn up which coverage(i.e., the GlobalAlliancefor Vaccine defined the roles of the contractor and provider, Initiative- GAVI). andthe incentivesand benefitsthatwould accrue to each party. There was limited collaboration 4 Product-development partnerships:Such outside the contractual agreement. Where non- partnerships involve market development contradual collaborations existed, such as those support for a public health good. The between pharmaceutical manufacturers and partnership covers some of the risks publichealthagenciesforthedonationofvaccines associated with product discovery/design, or treotments, theywere informal and depended development and /or commercialization/ on the mandate and motivation of individual marketing(pushfactors, for examplePersonal privateand publicsector entities (Widdus 2001). 1) Bar I. b d r l a ( lpcw~nership.forinfrac)ructureservices ~ ~ I British polick towardsthe pr- m r havebmnbrerunners of gkrbaipolicy. Thirty yearsago priit. mdvmadinl-re secbr service WE reafridedto scham# toh i l d idmfmdure, s u c h c a ~ k t d g r s , a n d v a i e r n u p pk~r. t h e E a ~ ~ d t h b 1 9 8 b , w h b l e privdidion 6nd dsmgutafwn of @#c sador rervkPc t d pbm.Tha rkrle diveshdibdfof its in)ered in railways, airlines, stme) urrd motor prodvciim, water, gas, electticity, a d iokw~untrcmons.W W n m lwilh mmdlhew u l b hur krdfoomaremodera%state af prhrak&t inv-t when the rded government is to re@u.!&ecmd 6-d he pubk good. kdmy it isNQeootod thcd 'reg* k fhe new priwfrzotion." m the 19!?0s, puMc re+ hBritain&d eraofthe P r k bFinonceIniliafivm.(PfI). PFt the hcls mcoumpd d-hdpmj.ctr hbeundukdm~Lythepn'vahe r md provkhdmmmthra lor the private r e to fake tho Min pid venkrra with he pubr~m. date TO h a m m g e d r h r )e, hpi#rl mim per power, wm&e incinedon, and didysis smWiOl),s&o&, @om, waler, sswarqm, a d frmsport. Thm u u of PPPr is a key chrnmd d the current gcmmm&+r strdmgy for ~~modern, higb- pbkmvhsWh&a h e projects r d y representwlurc for money tofhe public mains 0 contrmnnmf wbioct. , The rise of neo-liberal ideologies, such as globalization, free markets, privatization, and competition, in the late 1970s and early 1980s coincided with the international debt crisis of A partnership can flourish only if both partners 1982. The poor performance of state-owned gain from it. The gains to the public sector of enterprises and governments' unsuccessful investingin healthare clear. Inthe privatesector, involvement in market processes in many there are a variety of potential gains from countries became apparent. This was followed investing in health and joining PPPs. For the by a wave of deregulation, liberalization, and privatesector profitsare critical, but they are far privatizationacross the globe in the 1980s and from the only consideration in deciding where 1990s. The performance risk for all projects to invest resources. If potential profitability is a shifted from domestic taxpayers to private prerequisite to investment in an activity, other investors. Subseqc2ntly, influential international concerns can and do intervene in making organizations beganto champion a greater role choices. At any given time, a company's senior and more responsibilityfor the private sector in managers are considering several potentially providing efficient and cost-effective public profitable products. Sometim,?~choice is services (Buseand Walt, 20000). determined by subjective factors and personal PPPsemergedas a resultof five contextualshifts: preferences-Most managersare also motivated by the desire for respect in the community and An ideological shift in the 1990s from to contribute to improving the quality of "freeing" the market (i.e., liberating business life-investing in products and alliances to from restrictive bureaucracy) to "modifying" meet public health objectives appeals to these the market (i.e., creating a facilitating broader sensibilities (BASICS, 1999; Slater and environment); Saade, 1996). A growing disillusionment with the UN and Industry and the public sector may indeed be its agenciesand their overlapping mandates, looking for similar benefits. A private sector parallel programs, and interagency manager wants the consumer's vote in terms of competition; Ichoice of his or her product. The public sector politician is looking for votes for their policies. An increasing recognition that the health Publicsector politiciansaimfor economicdevelop- agenda is so large that no single sector or ment, which is alsoa prerequisitefor development 'organization can tackle it alone (Buse and of theconsumerproductmarket. HindustanLever, Walt, 20000); for example, would liketo investinthe water and A realization that the market alone cannot sanitation sector in India so as to create an solve the problems of the world's poorest. environment in which more will eventually be Pub1ic.involvementisneededif healthservices, spent on hygiene products (Curtis, 2000). drugs1and vaccines Ore reach the Table 2 summarizes the potential benefits and (Widdus, 2001); and contributions to the public and private sector 8 A growing interest among private players to partners in the PPPfor handwashingwith soap. enhancetheir involvementinsocial issuesand In this case, the private sector can improve its to be seen as ethicslly and socially image, whichwill reflectin its brandequityvalue. responsible. Forexample, Unitever's mission Workingonsuch projectscandid staff motivation statement declares that "corporate social and retention; offer insight into the workings of responsibility is an integral part of our governmentand development agencies and the operating tradition" (Unilever). nature of future markets; and offer access to international knowledge and to public infrastructure.The publicsector shouldalso gain from joining this PPP, not only in terms of improved public health and associated savings, but from learning how industry carries out management, marketing, and communications. 'Ibble1. ExampkdWPsintheM t hsector: theiraims, parhwrs,and'mp#t teated nets and anti- malarial drugs, research wc development agencies, .initiativessuch as NetMark Handwash PPP (Curtis, 2000) * I Sdndvdc~nand rn m-fof- laflmce in dwkpmbnt and r -+dmdcaemmm M. g 0 e - mrtuHmg, a d cammudediora lmbhi b,te th. natum sf btrrrr vf nnkelr m u d d m i h # m c n - rr ~ t a l h T k d m d b t b m M ~ ~ m d ~ A c c r u b ~ ~ u r t o ~~~ . . m~ai.akndw-b: r GO* & -P r w - h m w C e h m kdHdY d r c l m w t -* B c m n m m t m h ~~~~i B d p ~ ~ ~ r k k n 1h-bdudd.rul.bpmm 11 2001), which could result in greater spending 5 Philosophyand basic I on drugs and other health products rather strategy - --- ----- L than on primary health care and the - --- prevention of infectious diseases. Counter- While the advantages and disadvantages of arguments are that through profit-driven PPPs will continue to be debated, the growth, industry has been responsiblefor the underlying issue of philosophy cannot easily global economic develop-ment that has be resolved (Seedhouse, 1997).There are two improved health around the world. Such extremes of political opinion on the subiect. opposing ideologies cannot be reconciled While, on the one hand, collaborating with simply by the marshalling of supporting facts. the "evil of global capitalism" is considered Possiblecosts and benefits, both internal and unacceptable, on the other, it is felt that the external to the PPP, must be carefully only solution to the problem of development exomined to evaluate their wider impact. i s the operation of the free market. Hancock (1998) suggests that working with industry STRATEGY may be incompatible with improving health The case study review (inAnnex 1) and available since the options for increasing profit- literature suggest that there are a number of producing and selling more, reducing strategies that can enhance the success of production costs, rationalizing the workforce, partnerships. These include employing the and increasing prices-may lead to the principlesof good governance, the selection of depletion of resources and increased appropriate partners, transparency, account- unemployment and poverty. It has also been ability and good communications, fair suggested that the public health agenda may competition, equity, and the evaluation of be captured by industry (Buse and Woxman, externalities. Good governance structures of the partners inthe PPP (vonHayek, 2001). According to the WHO guidelines on A governancestructurethat fits the needsof the PPPs, key stakeholders who do not have the partnershipis necessaryto ensurethat the public resources to attend meetings of governing health objectives and the objectives of all the bodies should be subsidized to take part (Buse partners are being met, and that there is and Waxman, 2001). transparency in communications. Based on a review of health partnerships, four models of Partner selection govemance were identified (Buse and Walt, 2000b): The public sector should choose its partners so as to cover the targeted market segments and maximize coverage. The review suggests that privateand public sector organizationscanwork together to supportdiseasepreventionprograms ifthey havea perceivedmutualbenefitandthere is a win-win situation. When one partner is not convinced of its benefit,the partnershipcan fall apart (seethe NetMark case study). Transparencyand communications According to Buse and Walt (2000a), the "effectiveness" of PPPs in the health sector is enhanced by transparency and easy communicationsin the following seven areas: (1) cleody rpsc#ied, mdidk, and shared goals; (2) c k d y d d k d ond agreed roles and mqwdblitim; (3) dRtblCt b e d hfor 4 partnew; (4) the percaplion ef tronrpcrrency in tha pubkc eye; 15) advo "mainte.nenceuof the por+nenhip (i.e., resolution of conflict, rmgvlar mdngr, *.I; (6j equal pcnficipotiwl; and (7) honoring awed ob@ations. Both the finances and the actions of PPPs are subject to particular public scrutiny. Without transparent structures and careful attention to the wider spin-offs from a PPP,they are open to criticism for wasting money or being unethical or even damaging (UNDP). Working with industry may offer new opportunities for To find an appropriate governance model, von corruption or dishonest dealing. Wheeler and Hayeksuggeststhat these and other governance Berkley (2001) suggest that public sector modelsbe explored inthe light of the objectives partnersmayneedto investmoretime and effort of the partnership, the principles of good in explaining their strategies and commit more governance, and the existing governance resourcesto communicationsthan their private sector counterparts. Partners should be Equity happy to have everything they do or say One of the reasons for setting up PPPs is to appear on the front page of a newspaper addressthe issueof equityandtherefore should (Hancock, 1998). not work against that through inappropriate Ruchat and Dal's review of the Global Polio market interventions or subsidies. Private Eradication Initiative suggests that creating a markets often do provide goods and services joint communication strategy is difficult but that are affordable for all (Widdus,2001).The necessary. The process of producing a Roll Back Malaria initiative currently supports "partnership" document and reaching targetedschemesto subsidizenets, insecticides, consensus on the final product was slow and or both, for vulnerable population groups. A difficult. The lesson learned was that they had PPP should have a strategy to ensure equity, to be willing to accept the lowest common particularly when public contribution has been denominator in the interest of the partnership raisedwith the purposeof helping the poorest. "Everybodywants brands. in producingpublicinformationor mediapieces W Externalities (Ruchat and Dal, 2000). And here are a lotmore Externalities are the spillover of benefits or Poor people w Accountability harms beyondthe immediateaims of a project. in h e world than rich As PPPs employ public resources, they are For example, the positive externalityin treating people. accountableto the public. PPPsshould be able a communicable disease is that it impacts the entire population rather than the individual To be a global business... to demonstrate that public resources are being effectively employed. Given that service user (Smith et al., 2001). GAVl's you have to participate ,program to reduce mortality from vaccine- considerable resources may be expended to in a//segments." set up and operate a PPP, when partnerships treatable diseases in developing countries will impadthe larger population in terms of health ultimatelyfail, the cost to the public, including Keki Dadiseh,Unilever carecosts and qualityof life. PPPsmayalso have opportunity costs, could be substantial. The (Balu, 2001) a negativeimpactsuch as on localemployment public sector can easily underestimate the and income when local markets are disrupted. time and effort required and overestimatethe All externalities need to be carefully assessed chances of success of a partnership (Webber when planning interventions. and Kremer, 2001). Effective monitoring a i d evaluation are required, and audit and oversight from independent bodies should be ( 6 Lessonslearned encouraged. Avoiding unfair competition PPPs should be based on win-win PPPs may have unintended consequences. partnerships, where both partners have an Unfair competition and diminished interest in carrying out mutually agreed- sustainability can become issues when public upon activities. Industry may need to be funds are used to subsidize products that are given incentives not only for being in the already available in the local market. In partnership but also to continue with it, Indonesia for example, heavily subsidized for instance, bad image or loss of public condoms dominated the condom market and sector support for bowing out. reaped most of the benefit of public sector Expectations of who is to contribute what support. This threatened to de-motivate the may be at serious variance. All parties commercial sector and could have resulted need to agree upon products and in the disappearance of local condom brands endpoints, and ways to measure them at from the market. Similar consequences were the outset. Each partner's responsibilities noted with the NetMark project for the toward these ends need to be defined and promotion of subsidized bednets. A PPP needs agreed upon at the start. to explore how subsidy and promotion will impact local industry and the sustainability Partners should trust each other. When of the partnership. industry and government have little experience working together, it takes institutional obstacles remain unresolved considerabletime to build up understanding (UNDP). and trust. A neutral broker, who understands both sides and can "translate," is useful. All potential privatepartners should begiven the option to participate. Although larger Industries with a record of damaging public corporationsmayfind it easierto collaborate health either directly (by dealing in arms or becauseof their resourcesand international tobacco, for instance)or indirectly(thosethat culture, specialeffortsare neededto include are polluters or have poor labor relations) smaller players. It is worth noting that may be inappropriate partners for health working with a single industrypartner could PPPs. It may be helpful if prospective private meanthe collapseof the initiative shouldthe partnersare requiredto passan ethicalaudit partner pull out. (Hancock, 1998). Subsidized products can crowd out local R A transparent system of governance is marketsfor health-related products, thereby required-set up either as part of an affecting sustainability. On the other hand, international agency or as a separate legal the promotion of a brandedproductcan lead entity. Resources are needed to ensure the to an overall increasein the demandfor that participation of stakeholders, such as local product category and not just the branded manufacturers' associations, who might product (i.e., the halo effect). Public funds otherwise lack the ability to participate. should support and develop local markets where they have the potential to operate m Without leadership or representatives to effectively. champion the cause in each sector, agreement is unlikely to be forthcoming and If PPPs create a demand for products, then the underlying legal, political, and supply must keep pace. Efforts to stimulate demand must be coupledwith action to help local manufacturers adapt their production processes. GAVl has been effective on both ends, in increasingthe demand for vaccines and encouragingpharmaceuticalcompanies to supply and/or produce vaccines. Marketsdo not operateperfectly, andindustry may needto be pointed in the direction of a market opportunity they have not yet perceived.The role of the publicsector might be to point out a source of potential profit that had gone unnoticed. The possible negative and positive spin-off from the PPP should be constantly reviewed. Does the PPP help large international companies at the cost of local producers? The PPP needs to examine the effect of the initiative on the mostvulnerable groups and design a strategy to ensure that this target group is effectively reached. 8 Considerableresourcesshould be allocated to effectivecommunications, bothwithin and external to the partnership. All the activities of the partnershipshould be recordedand put up for public scrutiny. The minutes of meetings can be posted on the projectwebsite and externalfinancial audits conducted. 8 A generic campaign may not be as effective as a branded campaign. Encouraging individual manufacturers to promote their own brands in collaboration with a public healthmessagesponsoredbya publicagency (i.e., washing handswith soap X) may be the most effective strategy. A PPP dealing with multiple industrial partners cannot support individual brands. Annex 1 Case Studies of PPPs in Health PUBLIC-PRIVATE PARTNERSHIPTO PROMOTE HANDWASHINGWlTH SOAP INCENTRAL AMERICA This inifiative brings together public and private sector partners to increase awareness of the health benefits and market opportunities of handwashing with soap. The handwashing program is being promoted through a large-scale communications strategy aimed at decreasing the incidence of diarrheal disease. Parinerr: USAlD through two funded projects, Basic Support for Institutionalizing Child Survival (BASICS)and the Environmental Health Project (EHP), the soap industry, Ministries of Health and Education, media organizations, donors, and NGOs. Table 3. Benefits to and contributions of partners in the Central American HandwashingInitiative Oovemanec: BASICSand EHPplayedthe roleof catalystsfor the partnership,bringingtogether unlikely partners and acting as mediators between the public and private sector to meet the objective of promoting handwashing with soap. IMPACT A major benefit of the handwashing initiative was building awareness in the private sector that public health objectives are compatible with business opportunities. Soap producers learned that there is a way to advertise soap and promote handwashing. Inthe public sector, the initiative led to bettercommunication on handwashing and health. The coverageof existinghygieneprograms increased, and soap sales increased (Saade et al., 2001). LESSONS LEARNED Role of the catalyst. Catalystsplaya crucial role in market research and development of a communications strategy, in addition to facilitation and coordination of the partnership; they foster a sense of ownership of the initiative among the partners; have a clear vision of the project's goals and help partners stay focused; ensure that roles, responsibilities, and expectations are clearly articulated, that processes are transparent and agreements documented; they have a local coordinator to follow the partnership constantly and maximize the participation of all players (Saade et al., 2001). Sustainability. As financial and technical support rests with the companies themselves, sustainability depends on the involvement and leadershipof industry. Inthis case, there were some limited long-term activities in handwashing undertaken by industry after project funding ceased. Demonstrating public health impact. It is difficult to evaluate the impact of a large- scalepublic health intervention, especiallyonethat involvesa privatepracticesuchas handwashing. As a result, convincing partnersto continue or to embark on further projects may pose problems. Spending on effectivenessand cost-effectivenessevaluations may needto be substantial, at least in the early years, to test the validity of the PPP approach. Road map. All partners must have a clear understanding of the main elements and logical progression of steps. BASICS designed a model for implementation that listed the evolution of each step in the PPP shown as a nautilus, which could serve as a model for other projects (Saade et al. 2001). Behavioral research. Behaviorchangestrategieshaveto be basedon a good understanding of the target audience. BASICSdeveloped its communicationsstrategy basedon market research that provided information on the actual and potential market for soap and the behavior and attitudes of the target population vis-a-vis soap and handwashing. Roles, responsibilities, and expectations. Drawing up a Memorandum of Understanding (MOU) helps to define the roles and responsibilities of the partners, the goals of the initiative, and the expected outcomes. In this case, the terms were open-ended so partners could take advantage of emerging opportunities. Decision making. Joint decision making may cause delays but createsa sense of ownership for the project among all the partners. I I NETMARIC:PARTNERSHIPTO INCREASETHE USE OF INSECTICIDE-TREATEDMATERIALS TO PREVENT MALARIA The NetMark initiativeseeksto preventmalaria inAfrica bypromoting insecticide-treatedmaterials through the formation of PPPs. By acting as a catalyst with the Ministries of Health, international donors, and NGOs, NetMark haspromoted an integrated market segmentationmodelthat brings together the resources and strengths of each partner. More specifically, the initiative facilitates the entry of the commercial sector into the market by sharing the cost of market development to keep prices low and increase access. As the coverage of the commercial sector is extended, the limited resources of the public sector and NGOs can be better focused on reaching those who most need their help-the most vulnerable groups. Another benefit of this approach is that by collaborating with fhe private sector, donors and NGOs can focus on behavior change, leaving the commercial sector to handle product procurement, distribution, and brand advertising (NetMark). krhler~: AED, The Malaria Consortium, LSHTM, Johns Hopkins University, and Department of International Heatth, Group Africa. Table 4. Industryand public sector ban& and contributions to NetMark .-- .-w.m** ., &'* resistance(Mu) to makethemavailable andafford- Prefermiid pricing: lower-priced able to poorer ~o~dations drugs fvrr the poor B Providingtox b r e k to companies m Trainlng shopkeepers in malaria Catalyst role in developing the treatment market for drugs and insedicide- B Production of law-cost, treated materiak ide-treated nets I mrnance:Atechnicaladvisoryteamwith representativesfromtheWHO, Centersfor Disease Control and Prevention, Swiss Tropical Institute, the World Bank, UNICEF, USAID's BASICS, and CHANGE projects. IMPACT Much of NetMark's work in the two years since its inception has been in market and consumer researeh and determining the most effective strategy to promote insecticide-treated materials. This has involved negotiating with a private sector partner to manufacture the pre-treatment chemical while NetMark developed the market for nets. However, over a year after the initiative was launched, the private sector partner withdrew from the partnership because it felt the market could not be sufficiently developed. NetMark has now recruited another four partners, Aventis, Bayer, VSS, and a net manufacturer to support the initiative. LESSONS LEARNED Bmndjngandn&Ihy. The public sector should maintain neutralityin promotingone brandof insecticide-treatednetsover another. Cmwding wt. Distributing productsfree or at lowered prices could undermine the demand in the private sector for health products and lead to a "crowding out" of the market. At the same time, lack of coordination between different agencies pursuing the same goal of making the nets affordable to the poor caused the market to be flooded with free or inexpelwive nets, almost driving local manufacturers out of business. T u r i f f r e g ~ h hLoweredtariffs onthefinished productfavoredimportingthe netswhentariffs . on the raw materialswere not lowered. lnrrlkawl puperfy d#s. Inoffering a mass-produced product, the public sector must be wary of violating the patents on products already on the market (for instance, chemicaltreatment for bednets). Takingin- avcwnt the s o c ~ o n o m i stutus of Itre mrget popuhh. Offering a c productcheap (orfree) for a short period to stimulate demand ("crowding in") may not be effective if people earning an average income cannot afford the commodity. R& crnd msponu'bl&fk.At the outset, clearly delineate how the initiativewill be managed, and the responsibilitiesand benefits for each party. Keeping the private sector committed may mean entering into a contract or setting up a board of directors to whom they are accountable. Risk shatiq andmark.) opportunity.The privatesector needsto be convincedthat there is a market for their product and that risk is shared among partners. PARTNERSHIPWITH CONDOMMANUFACTURERSTO PROMOTECONDOMUSEINREDWHT AREAS ININDONESIA Under the USAlD HAPP initiative, FUTURESworked with the Consortium of I Concrrned Condom Manufacturers to promote behavior change and i m p h t a soaal marketing campaign to increase condom use among commercial sex workers and their clients in Indonesia. Partners: USAlDHAPP,FUTURES, and Consortiumof ConcernedCondom Manufacturers Governance: USAlD HAPP is responsiblefor overall coordination. IMPACT Condom use among commercial sex workers rose 30 percent in one year. Condom availabilityand visibility also substantially increasedin red light areas, as verified by store checks and digitized mopping. Table5. Indushyandpublicsectorbenefitsandcontributionstothecondomprogram in Indonesia Ikn$ib Devdopmentd a M e f h Segmenied pricing helped reach condoms differenttarget groupscmd led lo higher coverage w m w * m Asrw~raiolmfw~rtzKh Helped uwre rlrrloinPbil&t d into pcraebtwubfSonr I&vprldng (donor -cy nduced) LESSONS LEARNED Cmwding out the local market. Heavily subsidized condoms threatened to de-motivate the commercialsector as the subsidized brand dominated the condom market and reaped most of the benefit from public sector support. This could lead to the disappearance of local condom brands from the market E f k t of the moss media. An effective mass media campaign helps to increase awareness and heighten personal risk perception that ! precedes the adoption of protective behavior. It also helps to de- stigmatize condoms, create an enabling environment for selling and j purchasing condoms, and expand the condom market by increasing retail sales. Demonrtmhg market opportunify. The private sector will invest in disease prevention pragrams if it has incentives and the programs will generate returns. Conversely, the private sector will be de-motivated to invest if it does not perceive any market opportunity. For example, commercialcondomcompanieswill sponsor "entertainment-education" eventsorganized by NGOs if they are perceived to have promotional value for their condom brands. If NGOs fail to deliver value and a quality product, theywill not generate repeatsponsorshipof their eventsand activities. Sustoinabili~.The private sedor is inherently sustainable, as true commercial enterprises do not rely on public sedor support. PARTNERSHIPTO INCREASETHE CONSUMPTION OF IODIZED SALT INPAKISTAN The partnership seeks to address the problem of iodine deficiency by promoting the consumption of iodized salt. A social marketing campaignwas launchedto increasedemand. At the same time, manufacturers were convinced to increase production of iodized salt (www.psi.org). P-I: . UNICEF,CIDA, PSI, SMC and the Government of Pakistan. ,$> W n c e :The projecthasbeendesignedand managedbyUNICEF, V) t with funding from CIDA. PSI and SMP have been contracted to .z 9 implement the proiect. 22%z Tab* 6.industryand publicsectorbenefitsandcontributions / to the iodizedsalt partnership IMPACT Over 30 percent of all edible salt is being iodized. As a result of this U- initiative, which was launchediusttwo years ago, there are now over LY u z 35 million new users of iodized salt. =3 c 5 e 2 .z LESSONS LEARNED z- 5 linkingpublic k h h ohms with market 0pparhmi)y. Once the private sector is convinced that their product has a public health benefit and that there is a market for this, they will invest their own funds in marketing and product development. This will ensure the sustainability of the product. Bmndng and supportfrOmindurtrya s d d h s . Brandrecognitionis a powerful marketing tool. A keyfeature of the marketing campaign in Pakistanwas the creation of the "hand and pot" logo, which became a universal symbol for iodized salt in Pakistan. Salt manufacturers now use this logo to market their product. However, once the market was established some producers used the logo without iodizing salt--and there was no enforcement agency to regulate this. f n c s n h b r change hrolgh bgkhkn and d h ~Convincing private sector , players to invest their own funds makes the program effective and sustainable. For instance, a processorwho has purchasedhis own equipmentfor mixingand packagingsalt isfar more likelyto iodizehis productcorrectlyandconsistentlythan someonewho obtained hisequipmentand materials through a government or donor subsidy. Similarly, legislation requiring that all salt be iodized, while important, has been ineffective in countries where enforcement is difficult. To be effective, legislation on iodization of salt should accompany programs. Role of a catcrlyrt. International donors and governments are often not structured to work directly with the private sector. A catalyst organization, like PSI or BASICS, can provide the critical bridge between the public and private sector. kmand and supply. Creating a demand and increasing production should be simultaneous processes. PHASE: CLEAN HANDS, HAPPY HANDS, HYGIENEPROMOTIONINSCHOOLS - GlaxoSmithKline's PHASE project is a health education program that targets primary school children aged 6-13 years. It aims at reducingthe incidence of diarrhea-related disease associated with poor hygiene in Kenya, Peru, C6te d'lvoire, Nicaragua, and Uganda. P a w GlaxoSmithKline, Ministries of Health and Education, local NGOs. Govefnance: GlaxoSmithKlineprovides overall managementand the training materials. It collaborateswith local governments and NGOs in countries where it has operations. The partnership is seen as a long-term collaboration. T a b 7. industry and public sector benefih and contributions to PHASE Industry Public Sector IMPACT Increasedawareness, prevention,and treatment of worm diseasein Kenya and C6ted'lvoire (GSK, 1998).The initiative has been extended to cover Uganda, Peru, and Nicaragua. LESSONS LEARNED WshibutSon. Due to poor infrastructure, distribution in some countries (for instance, Uganda) may be difficult. 4. Collabomting with existing development agencies, such as the World Bank, can facilitate distribution and increase coverage. 2 Cu/h,m/ s m s i ~ It. is beneficial to create training 1 5 materials that can easily be adapted to regional contexts. Q I Sustainability. An exit strategy to ensure continued benefitsand expansion to whole countries on termination of GlaxoSmithKline funding is needed. THE GLOBAL ALLIANCE FOR VACCINES AND IMMUNIZATION GAVlwas set up in 1999with the missionto protect everychildfrom vaccine-preventablediseases. GAVl aims to close the gap in the availability of vaccinesto children in the industrializedworld and those inthe poorestcountriesthrough a global networkof international organizations, multilateral development banks, philanthropic organizations, and leaders in the private sector. Partners: Bill and Melinda Gates Children's Vaccine Program, International Federation of Pharmaceutical Manufacturers Associations, public health and research institutions, national governments, the Rockefeller Foundation, UNICEF, the World Bank Group, and the WHO. Governance: The initiative is governed by a board of directorsconsistingof top officialsfrom its members and is chaired by the Directorof the WHO. IMPACT Nearly three years after its inception, GAVl has introducedoutcome-based grants for developing countries. It has approvedfunding proposals from over 20 countriesthat have per capita incomes below US$ 1,000 and committed US$ 300 million to government health programsfor five years. This will helpto payfor new and under-usedvaccines and/or to improvethe current immunization services in these countries. Table 8. Industryand public sector benefitsand contributionsto GAVl LESSONS LEARNED Encouraging sustainub/e investments. Investments in immunization need to take into account the sustainability of the health system as a whole. In particular, donors' support for immunizationhas in some casesencouragedthe view that governmentsneednot includeit intheir own budgets. lncreusing su& anddamcrnd simuhmwusiy. Increaseddemand should be coupled with increasedproduction or procurement strategies. Many vaccines developed in the last twenty . years, such as Hib or pneumococcalconjugate, are governed by international patents and cannot be produced generically. They are expensiveto purchase and consequentlydifficult to procure. Outlining responsibiIhs of eoch partner )o ensure focused support. To ensure focused support, the costs of the immunization program should be clearly defined and targets should be established. & t a r , K ~ d A W h 1 ~ ~ % 0 1 . % & - R i r d , h r t n r d r l p : A w h r WHO. W b o f h W , 7 9(IIF7&54 . . B m ,K. d G,W.2000..WCvblic-Private PmthA N . r - b r M Bulletindk-8 (4): 549-81. &rrr, K . s r r d G W . 2 O O D k G k ~ P B ~ ~ M lkWketh k mfor Gbbd Cbwmnd &ddnddm WIO, 78 141699-7#. ~ ~ b # l h 3 h t C e d w y : ~ ~ f h r k .. b d U n a ~W,Dm.s ~ ~ Womrn, Tduasb, 21-14 Ckfdmr 1P99, OIO(lm b/ h i a r b tonrurfiurn, UNlCF, USAKl, fh WHO, and h h # r t s l M . W,M.1999.Ak v hd ~-~ h?mmhiprin Ha Public-Priroh hrfnrrship far Henlhvtllhg with m. Wu.r &E*vimnmclrrldSonWbn Seaor in hdm. m. --w.orcl. -0.1997. W S b R e r n h MbrPpSrX C m d k t d WW. Wlky. U i Skfw,S.HdC.Sada 1 9 9 b ~ I h . G s f ~ ~ o r d d ~ ~ zrubllc~A&Q&Eu-:A r hadwtb.wdiwm,0~ W,1999;8btusodbod.,I%'@. S*, C., II krghrr, old A. Xwl. 20bl. W i Mva;lr * s . d o r ~ w k k r r k ~ ~ C o r ~ : ~ ~ e b y G u i b . Ldndon:OpHom. Water and Sonahtion The World Bank 1818 H Street, NW Washington, D.C. 26433 -- Telephone: (+1 202)473-9785 Fax: (+1 202) 522-3313 Email: info@wsp.org Webski: www.globIhandwashing.w Task Managers: Jennifer Sara Paromlyar Authors: Ann Thomas Dr. Valerie Curtis July 2003 Y I CmQtadbyCnm Design AgoCiate5 Mn-