PUBLIC-PRIVATE PARTNERSHIPS IN GLOBAL HEALTH: ADDRESSING ISSUES OF PUBLIC ACCOUNTABILITY, RISK MANAGEMENT AND GOVERNANCE

Collaboration between organizations in different sectors of the economy is not a new development, but it has become increasingly dominant in the discourse on public sector reform (Wettenhall 2003). Partnerships between government and organizations in other sectors of the economy are now accepted as a promising way of generating new opportunities to leverage financial, human, and technological resources that will not be available if government goes it alone (Bovaird 2004, Savas 2000, O'Looney 1992, Linder 1999, Rosenau 2000). In particular, PPPs are emerging as an attractive strategy for leveraging the strengths of multiple sources in order to address health issues in low and middle-income countries. The promise, potential and challenges associated with PPPs are illustrated through examples of partnerships in global health, where particular emphasis is placed on strategies for public accountability, risk management, and governance. The purpose of this paper is to contribute to the needed effort to address this gap in the literature on PPPs in global health. Such a contribution, in turn, would be expanding our understanding of PPPs in general and bridging the divide between theory and practice in the fields of global health and public administration. Keywords: global health; non-profit and international partnerships; PPPs, public accountability; risk management; performance, governance.






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Publication: Public Administration Quarterly
Author: Martin, Marie H
Date published: July 1, 2012

INTRODUCTION

Collaboration between organizations in different sectors of the economy is not a new development, but it has become increasingly dominant in the discourse on public sector reform (Wettenhall 2003). Partnerships between government and organizations in other sectors of the economy are now accepted as a promising way of generating new opportunities to leverage financial, human, and technological resources that will not be available if government goes it alone (Bovaird 2004, Savas 2000, O'Looney 1992, Linder 1999, Rosenau 2000). Globalization and advances in technology require and enable governments to adapt to changing realities through innovative types of initiatives in the form of partnerships (Kinnock 1998, Bovaird 2004, Halachmi 2010b). Public- private partnerships (PPPs) have often been touted not only for their ability to increase efficiency and quality, but also for enhancing effectiveness, transferring or sharing risk, promoting coordination, and expanding resources for the attainment of goals that are in the public interest (Wettenhall 2003, Linder 1999; Halachmi 2010a).

While PPPs hold much promise, they are not without their challenges (Hodge and Greve 2005). Issues surrounding public accountability, risk management, and governance must be considered before passing judgment on the success of any given project that is implemented as PPPs. Understanding the nuances of PPPs requires mobilization of theoretical frameworks and models from several disciplines. Some of those are likely to address issues such as management practices, organizational structures, strategic planning or governance. Others are more likely to be closely related to the substantive nature of the PPPs, e.g., development of a transportation infrastructure, water system, health-related projects, etc.

With growing demands for health services and stagnation, if not deterioration, in the availability of resources, it is not surprising that increased attention has been focused on PPPs. Yet, it seems that most researchers have elected to use insights and conceptual frameworks common in public health and few have incorporated theoretical frameworks from the social sciences. The purpose of this paper is to contribute to the needed effort to address this gap in the literature on PPPs in global health. Such a contribution, in turn, would be expanding our understanding of PPPs in general and bridging the divide between theory and practice in the fields of global health and public administration.

The paper starts with a brief review of the literature on public private partnerships in global health, followed by an exploration of the relevance of PPPs in that context. The promise, potential and challenges associated with PPPs are illustrated through examples of partnerships in global health, where particular emphasis is placed on strategies for public accountability, risk management, and governance. The paper concludes by suggesting a possible direction for future research on PPPs.

THE ROLE OF PUBLIC-PRIVATE PARTNERSHIPS IN GLOBAL HEALTH

In the United States, thousands of partnerships have developed around health, fueled by investments of hundreds of millions of dollars from both governmental and non-governmental sources (Lasker, Weiss and Miller 2001: 179). According to the Initiative on Public-Private Partnerships for Health (2011) there has been an expansion of PPPs in global health since the mid-1990s. The current estimate is that there are around eighty such partnerships operating at the international level. Arguably, PPPs have become an essential part of the global health landscape (Reich 2002, Buse and Walt 2000a, Buse and Harmer 2004 and 2007, Brown et al. 2006).

There is a growing recognition that today's complex health challenges cannot be tackled by a single sector of the economy be it the public, private, or non-profit (Reich 2002). The attractiveness of PPPs is its promise, as a strategy, to leverage the advantages of each sector in order to achieve a better end result (Rosenau 2000). Widdus (2001), for example, notes that partnerships seem especially well suited for areas where diverse kinds of expertise are required to address complex problems. Buse and Harmer (2007: 261) identify seven specific contributions that PPPs make towards promoting global health:

* Getting specific health issues onto national and international agendas;

* Mobilizing additional funds for these issues;

* Stimulating research and development (R&D);

* Improving access to cost-effective health interventions among populations with limited ability to pay;

* Strengthening national health policy processes and content;

* Augmenting health service delivery capacity; and

* Establishing international norms and standards.

They define these as collaborations between public and private entities in health as 'Global Health Partnerships' (GHPs) (Buse and Harmer 2007). While GHPs may differ in structure, Buse and Harmer (2007) characterize GHPs by their shared decision-making processes. Widdus contends that the parties in such partnerships need to share common goals and objectives, balance power and responsibility in order to get mutual benefits (2001: 718). Buse and Walt (2000a) define a public-private partnership in global health 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 organization, so as to achieve a shared heath-creating goal on the basis of a mutually agreed division of labor" (p. 4). This expands the definitions of public-private partnership beyond the traditional partnership involving two sectors. As illustrated in Table 1, the recent evolvement of such arrangements brings to light additional concerns over governance, accountability and transparency that will be discussed at length later in this paper.

HOW HAVE PUBLIC-PRIVATE PARTNERSHIPS DEVELOPED IN GLOBAL HEALTH?

Dare (2003) argues that the rise in the number of PPPs in developing countries is a result of the difficulties experienced by their governments when it comes to provision of health services. The challenges confronting the public health systems in resource-limited countries include scarce financial resources, lack of adequately trained health providers and managers, complex socio-cultural and behavioral issues and a large burden of communicable diseases (Reich 2002, Lasker, Weiss and Miller 2001). In addition to serious challenges of access to populations in dire need of health services, the necessary drugs and vaccines may not be available or the distributions systems may adequate or dependable (Widdus 2001).

Historically, the private sector has not been motivated economically to engage in global health, in particular in drug development and delivery for the poorest nations of the world, but the situation is changing (Widdus 2001). The increasing awareness of the glaring disparities between rich and poor countries in health outcomes and popular expectations by the public and governments to see corporations demonstrating a greater notion of social responsibility are resulting in changes at a global level (Widdus 2001). A case in point is Bill Gates' pledge of US $ 2.3 billion at an international donor conference in London on June 13, 2011 to fund vaccination programs to protect children in poor countries against diseases like diarrhea and pneumonia (Croftand Kelland 2011).

Partnerships with the private and non-governmental sectors seem to be a promising path that low and middle- income countries can take to harness skills, expertise and resources that can assist them in tackling complex health challenges. Successful PPPs have an impressive record of being able to mobilize a significant amount of financial capital for global health (Buse and Harmer 2004). Indeed, one of the important contributions of GHPs to global health is raising the public awareness and consequently mobilizing resources to underwrite public health initiatives in low and middle-income countries (Buse and Harmer 2007). The past decade has been marked by a dramatic and unprecedented increase in aid funding for global health initiatives (Ravishankar et al. 2009). Between 2004 and 2010, U.S. government aid funding for global health has doubled from 4.26 billion to 10.67 (Kaiser Family Foundation 2010). From the highest level of government, there has been a commitment to addressing and ameliorating global health problems. A case in point is the June 13, 2011 pledge of the UK to provide £814m for vaccines for children in poor countries (Boseley 2011).

Propelled by concern for self-protection, economic stability, diplomacy and/or social responsibility, public and private entities have contributed in recent years billions of dollars toward promoting global health in low and middle- income countries (Lasker, Weiss and Miller 2001, Dare 2003, Garrett 2007). Yet, as noted by Hughes et al. (2008), resources beyond money are needed for dealing with the world's complex health problems. A collective effort and close collaboration among many parties are required to increase awareness of health issues and enhance the capacity of local governments and health systems to address issues of local and global concern.

Well-known initiatives like the Global Fund to Fight AIDS, Tuberculosis and Malaria, the Global Alliance for TB Drug Development, and the Clinton HIV/AIDS Initiative along with partnerships through the World Health Organization (WHO) have raised the profile of global health initiatives on the international stage (Reich 2002). Other types of partnerships like UNITAD, which is a tax on airline tickets in France that supports treatment efforts for HIV, malaria and tuberculosis, are shifting thinking on how global health funding is approached (World Health Organization 2006). Szlezak et al. (2010) contend that new partnerships between different sectors of society have expanded the opportunities for global health financing, shared expertise, and political action: "[t]hese partnerships have been emphasized - not least by the WHO itself - as the most promising form of collective action in a globalizing world" (p. 1). Brown et al. (2006) attribute much of this rise to the processes of globalization at work, such as technology and access to information, wich remains elusive to many in low-income nations.

'Social responsibility' has become a buzzword in the private sector since the early 1990s. At least part of the explanation of this development is due to a growing recognition by top corporate executives that engagement in efforts to promote the public good are not only valuable to business in their own merit but also very conducive for creating a positive corporate image (Carroll 1999). Advertisements showing a Phillip Morris truck bringing bottled water to flood victims or oil corporations protecting the environment are visual examples of this development.

The compelling rationale for entering into low- resource settings with goods and services goes beyond philanthropy and public relations. There are financial reasons for corporations to operate in countries with a high burden of disease where productivity is undermined by the costs of morbidity and mortality. Lasker, Weiss and Miller (2001) suggest that, "both public and private actors are being driven towards each other, with some amount of uneasiness, in order to accomplish common or overlapping objectives" (p. 180). Low and middle-income countries represent new markets so corporate presence is needed if such markets are to be taped. Arguably, corporate involvement in PPPs might be seen as a promising entry strategy that would generate good will facilitating subsequent economic and commercial penetration and capture of the said markets.

PPPS AND GLOBAL HEALTH: THE CASE OF GAVI

The global HIV/AIDS pandemic, along with the rise in attention to infectious diseases such as tuberculosis (TB) and malaria, have led to an increase in the number of PPPs (or GHPs) dedicated to vaccine research and development (Buckup 2008, Smith 2009). This subset of public-private partnerships focus specifically on product development for vaccines and other drugs have been termed 'product- development partnerships' (PDPs) (Smith 2009). The Bill & Melinda Gates Foundation recently pledged an additional US $ 10 billion over the next ten years to support vaccine development, research and delivery in the developing world. This is on top of the US $ 4.5 billion the Gates Foundation has already committed these efforts since it was established. The increase in funding from the private and non-profit sector signals a change in funding for immunizations and vaccine development, which experienced a decline in national funding from approximately US $ 182 million in health expenditures in 1990 to about US $ 51.5 million in 1998 globally ("Vaccine Availability," GAO/NSAID-00-4, 19). Product development partnerships are particularly adept at accessing financial resources as they often present effective and concrete science-led strategies for tackling health problems (Smith 2009).

One such PDP has been the Global Alliance for Vaccines and Immunizations (GAVI). GAVI was established in 2000 at the World Economic Forum as a partnership between multiple agencies in both the public and private sectors. The roots of GAVI are in the Children's Vaccine Initiative (CVI), which has struggled for years from a lack of leadership, autonomy and financial resources, unclear mission and targets, and minimal investment from and collaboration with the private sector (Muraskin 2002). GAVI was conceived with the recognition that the increasingly complex vaccine development and immunization process required partnership (Muraskin 2002). Muraskin argues that when GAVI was introduced, "things had matured to the point that no single organization-no matter how well managed and run-could do it all. The World Health Organization's weakness under Director-General Hiroshi Nakajima was hopefully correctable with the right leadership, but the vaccine job had grown so complex that only a highly committed partnership of international organizations, each with its own specific strengths, could successfully tackle it" (2002: 145). The Bill & Melinda Gates Foundation provided much of the financial resources to get the new public-private partnership offthe ground (Global Alliance for Vaccine and Immunizations 2011).

GAVI is comprised of organizations from all sectors. Representing the public sector are several national governments such as the United States, United Kingdom, Norway, and the Netherlands. The private sector includes philanthropists such as the Bill & Melinda Gates Foundation and the Rockefeller Foundation, the financial community, vaccine manufacturers and other private entities like the International Federation of Pharmaceutical Manufacturers Associations (IFPMA). The partners from the non-profit sector include multilateral organizations like the WHO, UNICEF (The United Nations Children's Fund) and the World Bank (Reich 2002; Global Alliance for Vacccine and Immunizations 2011). The goals of GAVI are to mobilize resources from all sectors to address global health issues. In particular, GAVI seeks to address extreme disparities between rich and poor countries when it comes to rates of immunizations and level of access to vaccines and their development.

Since its inception, GAVI has boasted much success as a public-private partnership. Between 2000 and 2015, US $ 4 billion has been approved for country initiatives and programs (Global Alliance for Vacccine and Immunizations 2011). According to the World Economic Forum, "Since its launch 10 years ago, the GAVI Alliance has saved over 4 million lives and has immunized an additional 250 million children in the world's poorest countries" (World Economic Forum 2011). More recent estimates from the WHO attribute GAVI's efforts to the immunization of more than 288 million children and five million lives saved (World Health Organization 2011). The alliance has worked to increase access to vaccines, strengthen health systems, and introduce new vaccines and technologies (Global Alliance for Vacccine and Immunizations 2011). In a recent editorial on GAVI, Lee and Harmer (2010) note that the organization has been extremely successful in increasing global awareness of vaccines and immunizations, consolidating markets to decrease the costs of drugs, and generating resources to support the mission of the organization. However, GAVI has also been subject to criticism in a number of areas, which will be explored in depth later in this paper.

GAVI provides an interesting example because of the heterogeneity of the involved partners and stakeholders, its programmatic initiatives and assortment of objectives it seeks to attain. Other examples of partnerships that pool resources from multiple sectors for drug discovery and development are the International AIDS Vaccine Initiative (IAVI), The Global Alliance for TB Drug Development and Medicines for Malaria Venture (MMV) and the WHO's Roll Back Malaria Partnership. While these PPPs each target specific diseases, unlike GAVI, they are ventures comprised of public agencies, private corporations and non-profit entities. These various aspects of diversity underscore the importance of the organization's governance, accountability, and risk management as PPPs.

CHALLENGES TO PPPS IN THE CASE OF GLOBAL HEALTH

Buse and Walt (2000a, 2000b) suggest that the landscape of partnerships for global health has changed significantly in the past 40 years. They note that in the 1970s most partnerships occurred between a donor and a recipient government (Buse and Walt 2000a, 2000b). However, the 1980s was a time of greater engagement with the private sector. Expansion of actors occurred in the mid- 1990s in global health, blurring the traditional lines of partnerships (Reich 2002). Non-governmental institutions throughout the world have long provided public assistance, either alongside government agencies or independently. Increasingly though, private foundations, individuals, non- governmental organizations, multilateral agencies, corporations and academic institutions are involved in social and humanitarian efforts on a large scale. This is important for a number of reasons. Not only does this expansion of philanthropy represent new and larger resources for addressing public concerns, it also brings new types of partnerships. In the area of global health, for example, the Bill & Melinda Gates Foundation has provided significant financial support to the development of public private partnerships (Szlezák et al. 2010, Hughes 2008).

The role played by actors from the private and non- governmental sectors, in particular, modifies the decision- making process. For non-governmental actors, issues concerning lines of authority and accountability are perceived and handled in a different way than they would be by representatives of nation states. The latter are always aware that they are primarily accountable to their own fellow citizens. Many assert that the power of large foundations to impact decision-making processes is significant (Szlezak et al. 2010, Ciccione 2010). Ciccione (2010) offers the following observation: "Nowhere is this more evident than with the visibility of the Bill & Melinda Gates Foundation, which reports assets of US$38.8 billion at the close of 2007 and has made significant contributions to the Global Alliance for Vaccines and Immunization (GAVI), the Global Fund to Fight AIDS, Tuberculosis, and Malaria, and the World Health Organization (WHO) itself - as a result it holds a seat on the board of just about every major health initiative" (p.48). Because these new non- governmental actors have independent access to resources others do not have, they possess new powers that governmental actors never had. For that reason in an organization as complex as GAVI (or other PPPs), it may not be possible to assign clear partnership roles to national governments or to assume that all the partners are equal.

GLOBAL HEALTH PPPS AND PUBLIC ACCOUNTABILITY

Through pooled knowledge, expertise, resources, management, and shared risk, PPPs are expected to be mutually beneficial to all the involved parties. However, if they are poorly designed or implemented, then there is risk of a failed partnership and potentially even more harmful consequences than in the aftermath of a failed simple contract (Forrer et al. 2010). As cited by Bovaird (2004), Löffler (1999) contends that such partnerships can result in a "blurring of responsibilities" and an absence of clear and simple mechanisms to ensure accountability. There is great risk that the fragmentation of responsibilities and their assignment to the respective partners will reduce accountability to the public. The reason for this risk is simple. In order for the partnership to work, each party must abdicate some of its customary control and share the remainder with the other partners (Löffler 1999). Daniels and Trebilcock (2000) suggest that a lack of accountability can doom a partnership. As a result, these challenges may negate the very advantages that a partnership could produce (Salamon 1995). It should be noted here that when government is one of the partners its own transparency requirements, e.g. audits or Freedom of Information legislation, may induce greater transparency of the PPPs. This, in turn, can mitigate the risk of lost accountability (as indicated in Table 2).

Recalling the previous discussion of governance structures, it should be noted that public-private partnerships tend to operate with limited direct public oversight. In fact, the freedom from such close and time- consuming scrutiny (which may lead to greater efficiency and flexibility) is one of the things that makes PPPs so attractive. However, in the case of global health the growth in the number of actors complicates any serious effort to establish effective arrangements to assure horizontal or vertical accountability. Each of the many stakeholders in such global operations (with their divergent goals) may answer to their respective trustees or boards of directors first and to the general public only second, if at all. The values and priorities that guide each of the various stakeholders may be in line with the expectations and or missions of their respective organizations. However, they may not be consistent with each other in consequences that effect not only performance but also the ability to establish meaningful accountability to third parties. O'Looney (1992) describes the public sector as being more focused on accountability and the private sector as valuing flexibility. Indeed, the goals of the public sector are dedicated to the public good whereas the private sector is driven primarily by profit. While these two goals may be unified in a single partnership, from time to time they can also be in opposition. For example, too much of risk avoidance in order to maximize profit by the "commercial" or non- governmental partner may undermine the public interest that justified the project. Salamon (1995) argues that such an issue may be present even in partnerships of non-profit organization (NPO) and government. This occurs in spite of the fact that NPOs and government share a more closely aligned mission of public service in contrast to partnerships with "commercial" entities.

These concerns involve issues related to governance, accountability, mission creep, motivation, and management (Salamon 1995). This demonstrates a unique accountability problem for PPPs in global health, especially for the public sector partner. Buse (2004) argues that partnerships are inherently unequal, illuminating the principal-agent conundrum: "When the public sector is carrying an alms bowl it is not in a strong position to dictate principle of good corporate ethics" (2004: 239). A criticism of GAVI in the beginning came from their allocation of resources to different initiatives. With only 10% of their budget dedicated to continued immunization efforts and 90% to new product development, there was a concern that profit generation was more important than improving the health of populations (Ciccione 2010).

Since PPPs exist as independent legal entities, they are required to operate under the legal regulations of the countries where they were formed (Wheeler and Berkley 2001). For example, MMV was formed in Switzerland and must abide by Swiss laws, and IAVI and the Global Alliance for TB Drug Development adhere to U.S. laws (Wheeler and Berkley 2001). Wheeler and Berkley (2001) argue that the legal status of these PPPs ensures accountability and transparency. However, Ciccione (2010) argues that regulatory mechanisms are especially important and challenges arise when regulatory mechanisms are not in place, such as for the Bill & Melinda Gates Foundation, which she argues, has "no accountability mechanisms, with no board of trustees and no obligation to be scrutinized by another public entity" (p. 48). What role do stakeholders play in determining the direction taken by PPPs? As mentioned previously, one of the largest single sources of financial support comes through the not-for profit Bill & Melinda Gates Foundation, which funded the development of the Vaccine Fund at GAVI with US $ 750 million (Global Alliance for Vacccine and Immunizations 2011). As the financing arm of GAVI, the Vaccine Fund provides vaccines and funding to the lowest resourced countries in the world. The prominent funding role played by the Gates Foundation has been met with some concern in light of their growing influence over agenda setting, and relative independence as a legal entity (Szlezák et al. 2010). The introduction of additional powerful stakeholders, with their own values, motivations and administrative processes, could potentially undermine public oversight and the transparency in the decision-making processes.

Increasingly, private entities are judged by the public and their stakeholders on their social responsibility efforts and commitment to promoting global health for the poorest nations in the world: "At the same time, private for- profit organizations have come to recognize the importance of public health goals for their immediate and long-term objectives, and to accept a broader view of social responsibility as part of the corporate mandate" (Lasker, Weiss and Miller 2001: 201). Innovative new underwriting schemes such as the co-financing policy of GAVI hold much promise for global health, but they can also lead to fragmentation and issue-specific agendas (Feachem, Yamey, and Schrade 2010) The area of intellectual property rights is contentious, but provides an incentive for drug development in developing country markets (Wheeler and Berkley 2001). As Reich (2002) argues, "a fundamental dilemma of such partnerships is to assure their accountability without suppressing their creative influence, entrepreneurial spirit or potential effect on improving the health of poor people in developing countries" (2002: 620). Additionally, lack of coordinated efforts can result in missed opportunities, or worse, conflicting agendas between partners (Gostin and Mok 2009, Ciccione 2010).

To address such challenges, efforts have been made towards creating "principles of best practice" by the 2005 High Level Forum on the Millennium Development Health Goals for PPPs (HLF 2005). These principles include ownership, alignment, harmonization, managing for results, accountability and governance (Buse and Harmer 2007, 262). Successful public management relies on effective public accountability tools (Kettl 2002). Each side must also consider how to hold the other accountable (Forrer et al. 2010). It has been argued that public accountability, sustainability and effective implementation of initiatives are critical features of successful PPPs in global health (Buse and Harmer 2007). Shared objectives and goals, especially in regards to reducing asymmetry of information and enhancing accountability should be clearly articulated in beginning of global health public private partnerships (Posner 2002).

GLOBAL HEALTH PPPS AND RISK MANAGEMENT

An important consideration for developing PPPs to address issues of global health is the opportunity to share or transfer risk. The private sector provides a viable partner for governments in managing and sharing risk (Hodges and Greve 2007). Nisar (2007) argues that strategies for risk sharing must be developed and in place for successful PPPs to be realized. Forrer et al. (2010) incorporates risk-sharing into their definition of PPPs:

Public-private partnerships are ongoing agreements between government and private sector organizations in which the private organization participates in the decision-making and production of a public good or service that has traditionally been provided by the public sector and in which the private sector shares the risk of that production (p. 476).

Bozeman and Kingsley (1998) describe risk adverse public managers, who are unable to take advantage of the new opportunities that their private sector colleagues can take because of the threat of a potential backlash from the general public. The risks associated with partnerships in the technology sector are arguably even greater than in other areas (Langford and Harrison 2001). Langford and Harrison (2001) suggest that the increased risk is due to the lack of knowledge of IT within government agencies along with limited experience. Often, the difference between taking general risk versus approaching opportunities from an entrepreneurship angle is not commonly distinguished in the public sector (Bozeman and Kingsley 1998).

Vaccine development is a risky business since it requires substantial funding, long-term perspectives and outcomes, much trial and error, and often little financial reward for the private sector (Smith 2009). This is particularly true for vaccines to prevent neglected tropical diseases that primarily burden the poorest countries. To drug manufacturers there is little promise of economic return from a population that has few resources to purchase medication. As such, vaccine development and distribution represents a classic case of market failure. There is little economic incentive for pharmaceutical corporations to invest in drug development for markets with few resources to pay.

As a result, the public sector is leftto research, design, develop, market and deliver many vaccines. Vaccine development has often been a more charitable exercise or one taken on by the public sector or academic institutions since there are few economic incentives for low and middle-income countries (Smith 2009). Many vaccine development firms have been incorporated into larger pharmaceutical corporations or have folded under economic pressures (Muraskin 2002). Incentivizing the private sector to join in partnerships with the public sector for vaccine development has opened up new opportunities to address diseases that disproportionately affect the world's poor, but it hasn't been easy process (Muraskin 2002). Sebastian Buckup (2008) argues that GHPs must actually respond to dual market failures: "on a first level they may tackle poverty induced lack of effective demand for health products which impedes the creation of market- financed innovative products. On a second level, they may help overcoming hold-up problems and underinvestment induced by complexity of neglected R&D" (Buckup 2008: 31).

New partnerships in vaccine development reduce the involved risks for large pharmaceutical companies and governmental agencies or non-profit organizations on multiple levels. Smith (2009) argues that partnerships for vaccine development "aim to stimulate private sector efficiency and engagement by providing incentives and reducing risks to encourage pharmaceutical companies to invest in vaccine development and utilize public-sector funding in a more effective way in doing so" (p. 346). In the complex and expensive area of research and development, these product development partnerships can share costs, expertise and time.

As vaccine development increases in complexity, the collaboration of sectors with different areas of expertise proves beneficial (Smith 2009). PPPs allow all sectors to engage in product development in a more entrepreneurial fashion: "Some organizations approach philanthropy as a form of venture capital. They bring innovation to the developing world and expect to see tangible results from their investments of material and intellectual capital" (United States HELP Commission 2007: 47). Public agencies have access to increased financial resources, human capital, and expertise as a result of partnerships. This can help mitigate risks for engaging in what the public may view as ineffective uses of tax dollars. Moreover, partnerships can help to pool resources from multiple sources, such as philanthropists, multilateral organizations, the private sector and donor governments, as GAVI, IAVI, and MMV have done. GAVI has sought to minimize the risks inherent in vaccine development by establishing advance purchase agreements (Global Alliance for Vacccine and Immunizations 2011). The International Finance Facility for Immunization (IFFIm) was created by GAVI to raise funds through the issuance of bonds in capital markets. This effort has garnered over US $ 3 billion for GAVI's immunization initiatives since 2006 and has limited the amount of risk inherent in the delivery of vaccines (International Finance Facility for Immunisation 2011). In exchange for providing reasonable quantities of drugs at an affordable price in the developing world, IAVI has allowed biotech companies to retain development rights (Wheeler and Berkley 2001: 731). Thus, companies can benefit from their participation in the development of drugs for low-profit markets through these types of partnerships.

As mentioned previously, vaccine development and delivery requires time. Smith contends that, "development funding is full of opportunity costs, and funding of high- risk science, such as HIV vaccine development, means that the public sector risks underwriting that risk and locking itself into funding long-term research streams that may not produce developmental impacts for several decades, if ever" (Smith, 2009: 347). The Bill & Melinda Gates Foundation, the World Bank and other donor countries have approached this issue through the development of the Advance Market Commitment (AMC) where donor's funds are committed to maintaining the price of vaccines when they are first developed. This commitment is reciprocated by private entities that enter into long-term legal contracts for the delivery of those drugs to resource-limited settings at affordable prices (Schieber et al. 2007, Global Alliance for Vaccine and Immunizations 2011).

Interestingly, there is an additional risk involved in the use of PPPs in global health that requires further exploration in the literature. An area of risk management that is important to consider for the public and not-for- profit sector is that of the integrity of private sector partners. Buse (2004) argues that: "Another important area of oversight concerns the selection of corporate partners and in particular, exercising due diligence in guarding against partnerships with firms that have poor records on corporate social responsibility and financial integrity" (p. 328). In addition, there are risks in raising unrealistic expectations about eliminating national health challenges due in large part to reports about recent success stories raising large amounts of funds and product development of some PPPs (Smith 2009). For that reason, the capacity to manage expectations becomes a critical attribute for successful PPPs. Developing such a capacity is a challenge when clinical trials are conducted in areas with a high burden of disease and limited understanding of basic science research (Smith 2009).

PERFORMACE MANAGEMENT

Friedrich (1940) paved the way for contemporary discussions of performance measurement in the public sector when he claimed that public administrators should internalize values of the public sector in order for public good to be achieved. Kettl (2002) suggested that performance measures foster accountability and help clarify roles and responsibility of the government. However, unlike the private sector where the bottom line is the ultimate measure of performance, the productivity of public agencies is often difficult to measure due to variety of reasons (Halachmi 2002). In fact, Halachmi (2005b) contends that performance measurement is only one of the options for managing performance. Halachmi (2005b) supports this claim through a series of case studies that highlight other factors that can affect performance. Holzer and Lee argue, "Public sector goals are more complex, and therefore progress is more difficult to measure; motivational bases of public employees are different; layers of rules and regulations often prevent public employees from improving the general public welfare in a timely manner" (1993: 2). The general citizenry adds another element to this complex situation, since the feedback from these stakeholders is influential (Buntz 1981). These concerns are summarized in Table 2 below.

Hood (1995) views NPM as a "framework within which many different values could be pursued effectively," presenting the opportunity for many functions in public administration to establish measurable standards. In a more recent contribution, Evan Berman (2006) proposes that initiatives to improve government performance are part of a continual process, responding to external and internal change. Clarity over the goals and use of performance measures, as well as who is responsible, is essential for successful partnerships (Kee et al. 2007). Performance measures are established to ensure productivity and effectiveness, but serve an equally important role in ensuring transparency, legitimacy and trust (Halachmi 2010a). This begs the question of 'accountability to whom?' Gostin and Mok (2009) argue that: "[a]ccountability in global health has been problematic. The WHO and other intergovernmental organizations are officially accountable to their Member States, but 'they often lack detailed and realistic targets for health outcomes or for the intermediate actions they take to promote health'" (p. 9). Paradoxically, global health PPPs are often issue-specific and fueled by a desire for quick results and measureable outcomes (Buse and Harmer 2007). This can be accomplished without considering larger health systems or the impact of such narrowly focused vertical programs.

In a 2010 editorial published by the Lancet, a call was made for greater emphasis on evaluation of global health initiatives (Lancet February 2010). Szlezak and colleagues argue that, "the ongoing global financial crisis makes the efficient and effective performance of the global health system all the more pressing" (2010: 2). Starling, Bruhga and Walt (2002) reported in an early evaluation of GAVI that the initiative's success will depend heavily on the effectiveness of local health systems, which struggle from a lack of human capital and expertise, high attrition, and poor supervision, among other challenges. These weaknesses negatively impact performance management attempts. Starling, Bruhga, and Walt posit that "inherently weak routine information systems in some of the countries will undermine GAVI's ability to monitor and reward improvements in immunisation systems" (2002: vii). GAVI has addressed some of these concerns through innovative performance-based funding arrangements and introduction of unique program monitoring and evaluation initiatives (Buse and Harmer 2007). The outcome-based grants, introduced by GAVI, were intended as accountability mechanisms for recipient governments' use of funds. While recipient governments are granted a considerable degree of autonomy in use of funds, continuation of funding is contingent of a demonstration of results. In 2001, an independent consortium hired by GAVI conducted the first country level data audit in an effort to ensure greater accountability.

These researchers also found that the pace of the application process was too fast and that health systems were often ill-equipped to handle the increased immunizations (Buse and Harmer 2007). Moreover, while the enhanced efforts towards immunizations were welcomed, "donors - especially those committed to sector- wide approaches - believed that the initiative took insufficient account of agreed mechanisms for country planning and prioritisation" (Starling, Bruhga and Walt 2002: vii). Additional research on performance management and outcomes is warranted, and well as greater understanding of transferring risk, public accountability, governance issues and other economic and social issues that involve cooperation.

PPPS AND GOVERNANCE ISSUES

Shared decision making between the two sectors is characteristic of successful PPPs (Forrer et al. 2010, Allan 1999). However, when the public sector is one of the partners, then government is ultimately responsible for the outcomes even if from contractual point of view it is not (Halachmi 2005a). Ghere (2001) argues that, "the public partner should seek a leadership role that defines the tenor of the partnership" (p. 448). Efficiency cannot be the only goal, as the public interest guides government. In Australia, there are examples of how governance issues arose as a result of partnerships with entities outside of government because the locus of control became diffuse and risk was not evenly distributed (Wettenhall 2003, Johnston and Gudergan 2007).

Rhodes (1996) defines governance as "self- organizing inter-organizational networks" and suggests that governments should enable networks like PPPs. Governance is viewed as a more widely encompassing concept (Rosenau 2000). Governance International (2003) posits that good governance is "the implementation by multiple stakeholders of quality of life improvements through agreed principles and processes of working together." Importantly in this context is the issue of risk management (see Table 2 below). Halachmi (2003a: 72) distinguishes between the terms governance and governing, in particular for risk management in the following way:

* "Governing" has to do with control while "governance" has to do with steering. Governing is the sole prerogative of governments because it involves the possible use of coercion while governance involves cooperation and collaboration among multiple governmental and non-governmental actors with diverse economic and non-economic interests.

* Governing is state-centered while governance assumes a polycentric (or at least a decentralized) institutional structure with the government apparatus as only one of several centers. Simultaneously, in concert or independent of each other, these centers are seeking legitimacy, initiating a variety of programs, competing for and mobilizing public and private resources.

* Governing takes place within the national or internationally recognized borders of a given polity while governance results from interactions within and across such borders. Governing assumes the existence of sovereignty and clear hierarchy of norms (i.e., a legal system) with actors playing either primary or subsidiary roles.

* Governance is multidimensional with actors playing a given role in one public policy arena and different role(s) in other public policy arenas.

Halachmi's (2003a) conceptual framework about the difference between governing and governance suggests that governance should be the preferred perspective for studying global initiatives concerning health issues. With this in mind, it is not surprising that skepticism about PPPs for dealing with global health issues has to do with governance issues in general and accountability in particular. The sheer increase in the number of PPPs in global health alone seems to fuel concerns over coordination and governance issues of such projects (Szlezak et al. 2010). As Buse and Harmer (2004) explain, "new forms of global health governance are emerging... wherein the commercial sector is represented, thereby pluralizing decision-making bodies and simultaneously reshaping relations of power, authority and legitimacy" (p. 50). In a complex global health partnership such as GAVI, concerns over internal governance structure are brought to light by the very composition of the GAVI Board of Directors, the ability of the GAVI secretariat (UNICEF) to veto decisions, and the inability of the Board to enforce decisions with partners (Widdus 2003; Buse and Harmer 2004). In 2008, GAVI's governance structure was reorganized to create a single body in an effort to merge public and private interests and expertise. This was an effort to clarify roles of organizations within the alliance (Global Alliance for Vaccine and Immunizations 2011).

Concerns of PPPs in global health have included the limited role played by recipient countries in priority setting and the risks of donor-driven agendas (Lee and Harmer 2010, Scheiber et al. 2007, Buse 2004). In response to concerns over the role of national governments, GAVI introduced a co-financing policy for vaccines that requires recipient countries to contribute to the overall costs with goals of enhancing sustainability and ownership felt by those governments (GAVI website 2011). Arguably, this provides an opportunity for the private sector to promote stronger and more equitable governance processes within low and middle-income countries (Buse and Harmer 2004).

Other concerns include the limited role played by other stakeholders, such as the beneficiaries of the programs (Walt and Buse 2006). As an example, the Country Coordinating Mechanisms (CCMs) that were developed by the Global Fund to Fight AIDS, Tuberculosis, and Malaria have struggled with limited or weak representation of community representatives (Walt and Buse 2006). These CCMs constitute partnerships responsible for developing proposals for funding and ultimately monitoring and evaluating those programs for the Fund. Limited representation by local beneficiaries on these CCMs has raised concerns of accountability and skewed power dynamics (Walt and Buse 2006).

Gostin and Mok (2009) suggest that as new partnerships develop, the governance structures will need to change. They contend that: "the global health governance system needs to find a way to create and align the incentives for the appropriate private/public actors and stakeholders to promote imaginative, well-funded solutions for global health improvement" (Gostin and Mok 2009: 5). Other arguments have been made for creating a new centralized governance structure within the WHO that would provide increased accountability, decreased transaction costs, enhanced trust, and protection of the public good (Ciccione 2010). According to Walt and Buse (2006), vertical partnerships, driven by nation states and multilateral institutions like the WHO, will be less influential in global health partnerships in the future. As noted previously, the expansion of actors in the field of global health and how partnerships develop and sustain themselves will continue to be an area rich for future academic exploration, particularly concerning issues of governance.

CONCLUSION

With the evolvement of the global village, closer cooperation and more efficient mobilization of knowledge, expertise, and financial resources are necessary in order to address many global health challenges. PPPs are emerging as an attractive strategy for leveraging the strengths of multiple sources in order to address health issues in low and middle-income countries. In fact, we have witnessed in recent years a growing consensus of the power of successful PPPs to affect positive social change benefiting all partners (Osborne and Gaebler 1992, Bovaird 2004). Recognizing that fiscal limitations and uncertainty will likely remain a part of the political landscape, there is an increased demand for tax money to be used efficiently and effectively. In this context, it is not surprising that along with the success stories there are concerns about the use of global PPPs to address health issues in developing countries. These concerns have to do, first of all, with issues of public accountability. When something goes wrong and former partners point accusatory fingers at one another, it is difficult to establish accountability or to assure that such fiascos will not be repeated. These concerns result from the inherent difficulty in addressing issues such as risk management and the governance of PPPs when the multiple partners are guided by their respective values and priorities that might not be consistent with each other.

Kort and Klijn (2011) note that the field of urban regeneration is an interesting area of study because of its recent experiences with PPPs. If one can imagine a government continuum that starts at one end with local governments, global health is at the other end having to do with projects that transcends the borders or policy arenas of any single government. Following Kort and Klijn (2011), we assert that the study of international partnerships to address global health issues in general and those involving developing countries in particular is equally as interesting.

Moreover, Widdus is correct when he argues that public-private partnerships in global health "should be regarded as social experiments; they show promise but are not a panacea" (2003: 713). The assertion that without these partnerships, little innovation would be available to address such complex health challenges, is not without merit. It seems to suggest that the use of global PPPs, even as a process of trial and error, should be condoned. We have articulated in this paper that public private partnerships are more compelling than the alternative of doing nothing.

Yet more in-depth examination of current PPPs in the area of global health and the mobilization of theoretical frameworks from multiple disciplines, to study its various aspects, would shed additional light on the strengths and weaknesses of this approach. In particular, longitudinal studies of PPPs that have been established to deal with global health issues seem to be an urgent issue. Such case studies not only would advance the understanding of PPPs, in general, but their better use for dealing with health issues in particular. In addition, the role that academic institutions should play in public-private partnerships holds much promise not only in terms of facilitating continued research on this subject but as a strategy for elevating in-house accountability. After all, the high standards of intellectual and scientific integrity that are expected to be upheld by researchers and the consequences of not adhering to them, make academicians the likely canaries to flag medical, administrative and ethical risks in the mines of global health.

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Author affiliation:

MARIE H. MARTIN

Vanderbilt University Institute for Global Health

Tennessee State University

ARIE HALACHMI

Tennessee State University

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