Appendix A

A Review of Public–Private Partnership Activities in Health System Strengthening

By Jill Jensen, Dr.P.H. student
Columbia University Mailman School of Public Health
June 20, 2015

INTRODUCTION

Global health programs and partnerships have historically focused on narrow, quantifiable aspects of global health challenges, especially communicable diseases on which they can make a measureable impact. Particularly in the context of the 2008 to 2009 global financial crisis, donors focused their investment on “high-impact interventions”—mostly vertical programs that could demonstrate “value for money” through decreases in disease-specific morbidity and mortality (Glassman et al., 2013). While metrics over the past decade show important reductions in the top causes of mortality (CDC, 2011), low- and middle-income countries (LMICs) continue to require support for crumbling health systems that fail to sustain program achievements and meet the demand for additional health care priorities. In the long term, vertical programs are only as effective as the health system in which they reside (Bloland et al., 2012).

Lessons learned from unsustained success in disease eradication, as well as failed responses to acute health crises, demonstrate the need for an enhanced approach to global health programming. Authors of the Lancet’s Global Convergence Series suggest a “diagonal” approach to health programming, which could support decreases in mortality in LMICs to the level of high-income countries (HICs) by 2035. In a diagonal approach, health system strengthening (HSS) activities—those that support key health system functions (Bloland et al., 2012)—are prioritized

along with vertical, disease-focused initiatives to create a system that can support the care for each person across his or her lifecycle.

A diagonal approach supports the equitable distribution of resources between disease-oriented programming and support for health system functions that are critical to sustaining any activity working toward improved health for all.

PUBLIC–PRIVATE PARTNERSHIPS

Partnership with the private sector is not a new idea—a 1993 World Health Assembly Resolution urged the World Health Organization (WHO) “to mobilize and encourage the support of all partners in health development, including nongovernmental organizations and institutions in the private sector” (Buse and Waxman, 2001). The WHO describes public–private partnerships (PPPs) for health as “public sector programmes with private sector participation” (WHO, 2015c), a vague definition that allows for many shapes and sizes of PPPs. A government partner sits at one end of the table, setting the priorities and rules under which private organizations operate (WHO, 2015c). On the other end are private for-profit entities, nongovernmental organizations (NGOs), and/or large multistakeholder initiatives such as Roll Back Malaria, the Global Polio Eradication Initiative, the Global Alliance for Vaccines and Immunization (GAVI), and the Global Fund for HIV/AIDS, Tuberculosis and Malaria (Dare, 2003). PPPs are actively involved in vertical programming, but only a few make HSS their primary focus. In fact, only 1 out of 90 international health-related PPPs in 2007 “focused on improving health systems beyond specific diseases” (Barr, 2007). Today, private-sector participation in HSS is slowly gaining momentum, as more and more PPPs are endeavoring HSS-related activities in accordance with the current emphasis on diagonal approaches to global health programing.

Innovative strategies for HSS are required to strengthen the platform on which vertical health programs are based. But how effective are PPPs for HSS? The Global Convergence Series recognizes a gap in the knowledge base regarding the “advantages and disadvantages of various mixes of public and private provision,” and whether PPPs “can improve effi-

ciency, access, and quality in health care delivery” (Jamison et al., 2013). Literature in this area is scattered—some articles detail the experience of private-sector providers filling gaps in public health care delivery. Other articles detail multistakeholder initiatives attempting to bolster the health workforce or access to and availability of medical products. There is limited evidence of PPPs addressing the health system as a whole; the author of this review found only two articles in which PPPs attempted system-wide activities. The author did not find any review articles that collated the experience of PPPs to better understand the advantages and disadvantages of various “mixes”—a gap that this review paper aims to fill.

WORKSHOP ON THE LONG-TERM PICTURE FOR HEALTH SYSTEMS: THE ROLE OF PUBLIC–PRIVATE PARTNERSHIPS IN HEALTH SYSTEMS STRENGTHENING

The National Academies of Sciences, Engineering, and Medicine established the Forum on Public–Private Partnerships for Global Health and Safety (PPP Forum) to identify opportunities that strengthen the role of PPPs in meeting the health and safety needs of individuals and communities around the globe, particularly those in LMICs. The PPP Forum sponsored a 2-day workshop on June 25 and 26, 2015, in New York City, to discuss PPPs as they relate to HSS. The workshop objectives were to examine a range of innovations, incentives, roles, and opportunities for all relevant sectors and stakeholders in HSS through partnerships; explore lessons learned from previous and ongoing efforts with the goal of illuminating how to improve performance and outcomes going forward; and discuss measuring the value and outcomes of investments and documenting success in partnerships focused on HSS. For the purposes of this workshop, the term “health system” comprises all actors, organizations, and resources working toward improved health for all. It is inclusive of personal health care delivery services, public or population health services, health research systems, and policies and programs within other sectors that address broader determinants of health. Additionally, a health system with robust public health services includes mechanisms for monitoring health status to identify and solve community health problems; diagnosing and investigating health problems and health hazards in the community; health promotion; community participation in health; developing policies and plans that support individual and community health efforts; enforcing laws and regulations that protect health and ensure safety; promotion of equitable access; human resources development and training in public health; quality assurance; public health research; and reduction of the impact of emergencies and disasters on health. Further, recognizing that the health of individuals and communities is influenced

by factors that are often outside the purview of the traditional health sector—such as the social, economic, and built environments—for this workshop the health system has been operationalized to include policies and programs within other sectors that address these determinants. Such sectors include finance, education, transportation, and information communication technologies, among others.

This literature review was prepared to inform the workshop audience of lessons learned during previous iterations of PPPs involved in HSS, in order to inspire PPP Forum members and the public audience to share experiences that might fill gaps in the literature, and discuss alternative models of PPPs that address obstacles experienced in the past. This review is structured around four major themes that emerged from the literature—service delivery, health workforce, medical technology, and laboratory systems—demonstrating the tendency of PPPs to focus on components of the health system instead of the health system as a whole. As previously mentioned, the author came across only two attempts at system-wide strengthening; these are discussed in detail to demonstrate the opportunities and challenges of PPP participation in health system-wide programming.

METHODS

The key research question for this review is the following: How have PPPs supported health system strengthening? The author of this review defined HSS as any activity aimed at improving the function of the health system, either by targeting a particular component or the health system as a whole (Bloland et al., 2012; WHO, 2007). Using the WHO definition of “Building Blocks,” these components include leadership and governance, financing, workforce, medical products and technology, information systems, and service delivery (Savigny and Adam, 2009); each are critical to all donor-supported and government health programs. In an effort to learn from past PPPs with the health system as the primary focus, the author initiated the review by conducting searches for peer-reviewed literature on EBSCO, PubMed, and Google Scholar using a combination of the following key terms: health system, health system strengthening, private sector, public–private partnership. The author examined the reference section of each article to find other relevant literature. Only peer-reviewed articles from 2000 to the present were included. To isolate key articles for the review, the author excluded articles that dealt with HSS outside the context of LMICs. The author also excluded articles that did not elaborate on a partnership between public-sector and private-sector entities. Public-sector entities could include national and local health

authorities, while private-sector entities could include community-based organizations, for-profit corporations, and multilateral organizations.

REVIEW OF THE LITERATURE

Service Delivery

According to the author, Berthollet Bwira Kaboru, a public–private mix (PPM) approach to health care delivery involves an integrated system of public health care providers and for-profit, not-for-profit, and/or informal providers (Kaboru, 2012). In Pakistan, 206 public–private service organizations and 600 nongovernmental organizations (NGOs) are providing health care services and conducting health-related research and advocacy (Ejaz et al., 2011). The Chief Minister’s Initiative on Primary Health Care encourages the PPM approach in Pakistan, through which 69 district governments—starting with the Rahim Yar Khan district—have signed memorandums of understanding (MOUs) with the Punjab Rural Support Programme (PRSP) to run basic health units in rural areas (Ravindran, 2010). Similarly, district health offices in Malawi have signed service level agreements (SLAs) with Malawi’s leading faith-based provider, the Christian Health Association of Malawi (CHAM), to operate rural health facilities; CHAM now operates 35 percent of all health facilities in the country (Chirwa et al., 2013). In Vietnam, private health care providers deliver 60 percent to 75 percent of ambulatory care and up to 4 percent of inpatient services. In all three countries, PPM is largely considered a “promising alternative” to the “inadequate”—and sometimes “inept”—public health system, which fails in particular to provide health care services for the rural poor (Chirwa et al., 2013; Duc et al., 2012; Ejaz et al., 2011).

A PPM approach to health care delivery leverages the inherent advantages of private-sector organizations. According to Ejaz et al. (2011), NGOs are particularly skilled in human resources management; they are able to hire and supervise staff more quickly and effectively than the Ministry of Health and local health authorities. NGOs are also able to promptly acquire specialized equipment and be more creative with health promotion activities. Furthermore, NGOs are perceived to foster better relationships with beneficiary communities. Chirwa et al. (2013) also emphasizes the advantages of incorporating private-sector provid-

ers into the health system, which includes increased technical efficiency and the ability to bypass “overly bureaucratic government procedures and overcome absorptive capacity constraints in the scale up of services.” Considering the impact on public health care facilities, both government and nongovernment participants in the study by Duc et al. (2012) were encouraged by the potential to reduce overcrowding in public health care facilities, thereby reducing government costs and giving clients more choices for services. The three examples demonstrate how a more effective integration of private-sector providers into the health system could relieve the burden on public health facilities while improving personnel management, use of technology, creativity in services, and community relationships.

A sustainable plan, however, for integrating private-sector providers in the public health system remains a challenge. Though the availability of CHAM providers in Malawi led to improved utilization of health care services in rural areas, costs escalated without reciprocal increases in reimbursement from the public sector. For example, Mulanje Mission Hospital experienced an increase of 23 percent in the utilization of maternal health services between 2006 and 2011, which resulted in a 56 percent increase in costs for these services. According to CHAM facility-level managers, quality of care decreased as hospitals struggled to balance insufficient resources with the rise in utilization. Overutilization also caused CHAM facilities to frequently run out of drugs. If the Central Medical Stores could not keep up with the demand, CHAM facilities resorted to purchasing more expensive drugs from private drug suppliers, leading to greater cost escalation. To make up for rising costs, some CHAM facilities unilaterally revised their service price lists; this list stated the price at which district health offices would reimburse CHAM facilities for services. Although district health offices did not approve these revisions, they simply could not afford to reimburse CHAM facilities regardless of the revisions, which lead to resentment, mistrust, and eventually the cancellation of many SLAs (Chirwa et al., 2013).

Inconsistent (or nonexistent) reimbursement, drug stockouts, and decreasing quality of health care services characterize PPMs in Malawi, Pakistan, and Vietnam (Chirwa et al., 2013; Duc et al., 2012; Ravindran, 2010). Other challenges with PPMs include ineffective referrals between private-sector health facilities and government-operated hospitals (Duc et al., 2012; Ravindran, 2010); insufficient integration of national health promotion programs with private facilities (Ravindran, 2010); mistrust due to the rapid introduction of private-sector providers without the consult of local government stakeholders (Chirwa et al., 2013; Ravindran, 2010); and a lack of human and financial resources at the district government

level resulting in weak capacity for regulation, monitoring, and quality assurance at private facilities (Duc et al., 2012).

Is reliance on private-sector health care providers for service delivery a stopgap or a permanent solution to the inadequacies of the public health system? The government’s reliance on the private sector, noted a donor agency representative, is an acknowledgement “that the government does not trust its own system,” and would not lead to an overall strengthening of the health system “unless the thinking changes at the strategic level and there is a clear policy push in that direction” (Ejaz et al., 2011). Private-sector providers remain an integral part of health systems, although there needs to be continued strengthening of public health care services to decrease reliance on the private sector and provide beneficiaries with comparable choices for quality health care services.

Health Workforce

The Emergency Hiring Program in Kenya is an example of how the business savvy of the private sector can strengthen a key component of the health system—the health workforce. In 2008, Kenya had less than two physicians (1.79) and less than four nursing and midwifery personnel (3.81) per 10,000 people (WHO, 2015a). Hospitals were overwhelmed with HIV/AIDS patients—384 people died in 2000 due to HIV/AIDS (WHO, 2015b). Kenya’s Emergency Hiring Program sought to address the health workforce shortage and the HIV/AIDS burden, which was exacerbated by the lack of knowledge about HIV/AIDS care. The Kenyan Ministry of Health, Capacity Project (a global initiative of the U.S. Agency for International Development [USAID]), and Management Sciences for Health founded a PPP to support the Emergency Hiring Program. Stakeholders from the Ministry of Health, Directorate of Personnel Management, Ministry of Education, and Ministry of Finance informed the program design. The group selected Deloitte & Touche, Kenya, to carry out the following core business functions: staff attraction, screening and selection, recruitment, training, deployment, payroll and benefits, management, and retention. Private academic and charitable institutions, including the African Medical and Research Foundation, Kenya Medical Training College, and Kenya Institute of Administration, supported health workforce training and exposure to best practices for HIV/AIDS care. The recruitment and training process took around 6 months; those who completed the process were given 3-year contracts, after which they were absorbed by

the Ministry of Health. At the time the article was published in 2008, 830 health care workers were hired, trained, and deployed under the program to 219 public health facilities (Adano, 2008). It is not certain how effective the new health care workers were overall, or to what extent the Emergency Hiring Program impacted HIV/AIDS-related deaths. The author also provides no comment on partnership dynamics. WHO statistics, however, demonstrate country-wide reductions in HIV/AIDS deaths—from 384 deaths in 2000 to 127 in 2012 (WHO, 2015b). Kenya also experienced increase in the health workforce between the publishing of the article (2008) and 2012—from 1.79 to 1.89 doctors per 10,000 people, and from 3.81 to 8.22 nurses and midwives per 10,000 people (WHO, 2015a). This area of PPP activities would benefit from a discussion of indicators and measurement tools to assess the impact of health workforce recruitment and training programs.

Medical Technologies

Incentivizing pharmaceutical and vaccine development for diseases that primarily impact LMICs has always been a challenge. “[D]eveloping and producing vaccines is a costly business, and the incentives to invest in vaccines appropriate to the disease profiles of the developing world are not sufficient. It is what economists call a ‘market failure’” (Adlide et al., 2009). PPPs endeavor to fill the gap in development and access to pharmaceuticals by leveraging the strengths and resources of public-sector institutions, academia, the pharmaceutical industry, the biotech sector, contract research organizations, and NGOs to meet the need in LMICs (Croft, 2005). As a PPP, GAVI consolidates demand in LMICs to incentivize pharmaceutical production, and then speeds the availability and use of drugs through partnerships with industry, multilateral agencies, and beneficiary governments. Individuals who are integrated in GAVI’s governance structure are key to the PPP’s success, contributing technical skills in their respective areas to solve issues related to drug development and access (Adlide et al., 2009).

Many PPPs focus just on the product development side, bringing together the strengths of the public and private sectors to develop new drugs for neglected diseases. According to the author Simon L. Croft, disease expertise is typically housed within academia and the public sector; these experts provide “the technology and ideas from the genome to the structural biology that enables rational drug design” (Croft, 2005).

Industry employs its skills in pharmacology, assay development, toxicology, scale-up chemistry, and formulation to translate these ideas and knowledge into the development of safe and effective pharmaceuticals. Examples of product development (PD) PPPs include Merck’s partnership for onchocerciasis, Pfizer’s partnership with the International Trachoma Initiative, and the GlaxoSmithKline (GSK)/Merck partnership with the WHO for lymphatic filariasis (Mackey and Liang, 2012).

The WHO’s Special Programme for Research and Training in Tropical Diseases (TDR), a collaboration founded in 1974 by WHO, World Bank, and the United Nations Development Programme, provides funding for disease research and pharmaceutical development using international, governmental, and philanthropic contributions (Croft, 2005; Mackey and Liang, 2012). TDR has funded several PD PPPs, including the Global Forum for Health Research, the Multilateral Initiative for Malaria, the Medicines for Malaria Venture, the Strategic Initiative for Developing Capacity in Ethical Review, Drugs for Neglected Diseases Initiative, the Forum for African Medical Editors, and the Foundation for Innovative New Diagnostics (Zicker, 2007). TDR also assists in procuring raw materials, conducts quality control, and exposes PD PPPs to the tools and networks they need to advance drug discovery and development.

One example of a TDR-supported PD PPP is the Medicines for Malaria Venture (MMV). Established in 1999, MMV has recently accelerated the development of novel synthetic peroxides, a component of the antimalarial drug, artemisinin. Development went from basic chemistry to clinical trials in just 4 years, involving scientists from the United States, Europe, and Australia (MMV, 2002; Vennerstrom et al., 2004). According to Croft, keys to success within this PD PPP include clear objectives, regular interaction among and between researchers, the MMV, and industry, and feelings of loyalty, commitment, and enjoyment in the work environment (Croft, 2005).

PPPs that support drug development and access benefit from the unique skills each partner brings to the process; however, they continue to struggle with establishing a sustainable and effective partnership structure. In a review by Kent Buse and Sonja Tanaka, GAVI and MMV were not without problems. At the time the review was written (2011), GAVI experienced a multitude of issues, including the following:

• “Need to identify and promote added value of partnership, accounting for evolving landscape”
• “Board members are unable to adequately represent their respective constituencies”
• “Poor transparency of governance and decision-making processes”

• “Weak strategic planning and/or lack of an overarching partnership strategy”
• “Weak partnership performance evaluation framework and accountability mechanisms”
• “Policies and funding allocations not based on strategic priorities”
• “Inadequate identification and support of cost-effective interventions”
• “Inadequate investment of effort in data collection and analysis to drive consensus on opportunities”
• “Mechanisms to promote country ownership are weak”
• “Inadequate support to building country capacity”
• “Country activities are not sufficiently tailored to country performance, capacity, and needs”
• “Inadequate support to strengthening information systems and monitoring capacity in country”

MMV experienced mostly different challenges, according to Buse and Tanaka:

• “Lack of sufficient governance mechanism to ensure inclusive and joint decision making”
• “Stakeholders and partnership priorities are not adequately represented by Board composition”
• “Secretariat structure/staffing does not support partnership effectiveness”

Both MMV and GAVI had two similar issues in common: “[p]oorly defined roles and responsibilities of partners”; and “[p]oor mechanisms to ensure long-term financial sustainability of programmes” (Buse and Tanaka, 2011). In fact, these issues are similarly experienced by PPPs involved in strengthening other components of the health system, leading one to believe that weak financial sustainability and inadequate definition of roles and responsibilities to be among the greatest challenges facing PPPs for HSS. Future discussions should examine the practical challenges and potential solutions to establishing long-term, flexible funding mechanisms, as well as defining and enforcing partnership roles and responsibilities.

Laboratory Systems

The role of national laboratory systems in health care service delivery and overall public health cannot be underestimated. Laboratory strengthening is a critical component of HSS; in fact, it is one of six key public

health functions “that would contribute the most toward health systems strengthening efforts as a whole and have the greatest impact on improving the public’s health” (Bloland et al., 2012). Laboratories are essential for surveillance, outbreak control, and clinical decision making (Bloland et al., 2012); more than 70 percent of clinical decision making is based on (or confirmed by) medical laboratory test results (Alemnji et al., 2014). And yet, like the broader health system in which it resides, national laboratory systems suffer from a dearth of professional staff, outdated equipment and poor equipment maintenance, weak supply chain management for consumables, insufficient quality control, and poor infrastructure—namely, inconsistent electricity and water, as well as crumbling physical infrastructure (Alemnji et al., 2014; Bloland et al., 2012; Nkengasong et al., 2010; Sturchio and Cohen, 2012).

The authors Nkengasong et al. (2010) outline the ideal comprehensive national laboratory strategic plan—essentially a systems strengthening plan—with similar goals as HSS: “(1) a framework for training, retaining, and career development of laboratory workers; (2) infrastructure development; (3) supply-chain management of laboratory supplies and maintenance of laboratory equipment; (4) specimen referral systems in an integrated, tiered [national laboratory system] network; (5) standards for quality management systems and accrediting laboratories and facilities; (6) laboratory information system; (7) biosafety and waste management; and (8) a governance structure that will clearly address regulatory issues and define reporting structures, authority, and the relationship between private diagnostic and public health laboratories” (Nkengasong et al., 2010). Were Bloland et al. invited to add to this plan, they would underscore the need for improved quality control, standardization, and accreditation; they would also add the following to the list: (9) stronger linkages among laboratories at the international, national, and subnational levels, and (10) integration among disease-specific laboratory networks.

Nkengasong et al. suggest PPPs play an important role in supporting the implementation of strategic plans for strengthening national laboratory systems. The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and Becton, Dickinson and Company (BD) lead one such PPP—funded to the tune of $18 million between 2007 and 2012. With the goal of strengthening national laboratory systems in eight African countries severely impacted by HIV/AIDS and tuberculosis (TB), the PPP focuses on training laboratory workers, improving the range and quality of services, developing tools and guidelines for quality control and quality assurance, strengthening TB reference laboratories to serve as training facilities, and improving access to diagnostics for TB. By 2012, PEPFAR and BD, in partnership with the Centers for Disease Control and Prevention (CDC), ministries of health, national reference laboratories, and local

implementing partners, had launched the initiative in Ethiopia, Mozambique, South Africa, and Uganda. The PPP adjusted training curricula according to the need of each country, addressing topic areas such as referral procedures for clinical specimens, record keeping, quality assessment, project management, and TB-specific services (including TB identification and drug susceptibility testing). According to a published article by Gary M. Cohen and Jeffrey L. Sturcio, executive vice president of BD and executive director of Rabin Martin, respectively, the PPP has already demonstrated improvements in the diagnosis of multidrug-resistant TB, patient management, and treatment outcomes. In Uganda specifically, the PPP trained 120 laboratory workers and improved quality management services in laboratories that serve almost 100,000 people on antiretroviral therapy (Sturchio and Cohen, 2012).

While the PEPFAR and BD–led PPP places a heavy emphasis on HIV- and TB-related laboratory services, Sturchio and Cohen imply that strengthening these services will benefit the overall laboratory system and broader patient population. The authors Wafaa M. El-Sadr and Elaine J. Abrams suggest efforts to strengthen HIV laboratory services could have system-wide effects if governments and donors support broader access to these services. The influx of international resources invested in the HIV/ AIDS epidemic benefits laboratory systems through newly renovated and equipped laboratories, technologies for CD4 cell count enumeration, and expanded availability of routine laboratory assays. Additionally, extensive training in HIV-related services provides access to new information and professional growth opportunities for laboratory and health care workers, which may contribute to the retention of these workers in the future. It is critical, however, that donors, governments, and other partners enable the broader patient population to access newly established resources through national policies and funding support. HIV-related services are generally free to those with HIV; thus, patients without HIV infection should also have access to these services at no or limited cost. El-Sadr and Abrams caution, “Unless similar support is made available for commodities and services for general health, infrastructure enhancements established through the scale-up of HIV services will probably primarily benefit only those with HIV disease” (El-Sadr and Abrams, 2007). An external evaluation of the PEPFAR and BD–led PPP is not yet available in peer-reviewed literature, but could reveal the impact of the PPP on the broader laboratory system and patient population.

“Whole” Health System Strengthening

Where most PPPs focus on a single component of the health system, occasionally a brave PPP will take on the health system as a whole. GAVI

and Pink Ribbon Red Ribbon (PRRR) are two such international PPPs that attempted “whole” HSS through initiatives that ran parallel with their regular activities. The article by Doyin Oluwolea and John Kraemerb is mostly an optimistic account of PRRR activities, while the article on GAVI is a critical perspective that describes aspects of the partnership that did not function well.

Pink Ribbon Red Ribbon

PRRR is a PPP designed to support cancer control—in particular, cervical cancer—in Africa and Latin America; however, Oluwolea and Kraemerb use the term “diagonal approach” to describe the partnership’s strategy of bringing together partners from across the health system and benefitting from existing vertical programs, such as those established for HIV/AIDS control, to strengthen the broader issue of chronic disease management. “In countries with strong, decentralized HIV service delivery systems, it is sensible and feasible to integrate HIV and cervical cancer services, a process that can be greatly facilitated by the experience these countries have gathered in the area of chronic disease management” (Oluwole and Kraemer, 2013). Four organizing members of the partnership include the George W. Bush Institute, the Joint United Nations Programme on HIV/AIDS (UNAIDS), PEPFAR, and Susan G. Komen for the Cure. Other members include BD, The Bill & Melinda Gates Foundation, the Bristol-Myers Squibb Foundation, the Caris Foundation, GSK, IBM, Merck, QIAGEN, and others. PRRR’s secretariat sits at the George W. Bush Institute and addresses gaps by working with existing partners. The PRRR Steering Committee, which acts like a board of directors, addresses high-level issues with the support of ad hoc working groups. In each country, the Ministry of Health leads a technical working group to develop the national strategy and plan for cancer control. Country-specific teams, which include a mix of public and private actors from PRRR member organizations, implement the national plan and coordinate activities.

The PRRR partnership has yet to conduct a formal evaluation of its impact on chronic disease management and the broader health system; however, future models of PPPs can learn from aspects of the partnership that operated well. Because cancer control requires a functioning continuum of care, the involvement of partners who represented multiple components of the health system—from pharmaceutical and vaccine developers, to health educators, to public and private health care providers—allowed PRRR to “capitalize on the particular efficiency and expertise of different organizations while avoiding duplication of effort among them.” For example, Merck and GSK were able to offer vaccines

for free or at discounted prices. Other private organizations were able to procure commodities rapidly and as needed. UNAIDS leant PRRR the credibility it had with government and civil society organizations, thereby enhancing PRRR’s community buy-in. To ensure all parties remained accountable, PRRR required pledges to be made publicly; every quarter, the country-level secretariat determined if commitments were on track and reported their status to all PRRR members.

Flexibility, adaptability, communication, and coordination are the main takeaways from the article by Oluwolea and Kraemerb. While the authors write little about the aspects of the partnership that did not work well, they do suggest an opportunistic approach to HSS. The speed at which private organizations can accomplish goals is generally an advantage, but the lengthy vetting processes of their government partners can frustrate these organizations. Therefore, the authors suggest a flexible, opportunistic approach that allows for support to be mobilized when high-priority needs are identified. And with all partnerships, the authors encourage well-planned coordination mechanisms and frequent communication.

GAVI

Even well-established PPPs have yet to master the art and science of maintaining partnerships and contributing to stronger health systems. According to the author Joseph F. Naimoli, the experience of GAVI in HSS “provides further evidence that the business of partnering can be complicated, messy, and rife with pitfalls, and the learning curve steep” (Naimoli, 2009). GAVI’s foray into HSS was motivated by criticism that the PPP was too vaccination-focused, and that it needed to find innovative strategies to support countries who that were falling behind on immunization coverage targets. Thus, the goal of GAVI’s HSS initiative was to improve immunization coverage and maternal and child health outcomes through a whole-system approach. The partnership did acknowledge the risks associated with undertaking HSS: not achieving value for money, inappropriate use of funds, unsustainability, and limited absorptive capacity on the side of national governments. Still, GAVI decided to pursue HSS in parallel with its regular vaccine-related activities. The role of GAVI’s secretariat grew to include agenda-setting, technical and procedural decision making, and conflict resolution. A Task Team (TT) chaired by the WHO, UNICEF, and the World Bank, launched, steered, and advised the rollout of HSS. Governance structures at the country level varied with each iteration, but included government stakeholders, civil society representatives, and NGOs.

In a thorough study on GAVI operations at the global and country lev-

els, Naimoli found countless deficiencies in design appropriateness, governance, management, monitoring and evaluation, and capacity building. In designing GAVI’s overall strategy for PPP, partners struggled to reach consensus given their different definitions of the health system, experience in HSS, and overall values. Collaboration within the TT also faltered due to unclear member roles/responsibilities and mutual accountabilities; irregular leadership and unclear lines authority; shifting mandates; unequal member influence; and inadequate processes for conflict resolution and joint decision making. GAVI’s crisis management style was a burden on GAVI partners and participating governments, who were not able to accomplish tasks with a high level of quality, or involve the right mix of stakeholders, given short deadlines and last-minute guidance. In accordance with monitoring and evaluation plans, many governments were not able to provide baseline data or support route data collection as required. Furthermore, partners questioned the appropriateness of indicators and targets, and whether or not they were in line with national health sector priorities. Finally, capacity building was seen as inadequate, with not enough partners represented at the global or the country level, and thus in the design or implementation of the HSS initiative.

“To its credit,” states Naimoli (2009), “GAVI has taken a bold step in trying to carry through on the long-standing challenge in global health to bridge the divide between vertical and horizontal modes of delivering priority health services.” Indeed, future models of PPPs can learn from GAVI’s experience in order to form innovative strategies for HSS and diagonal approaches to global health programming. In the meantime, GAVI’s HSS initiative is characterized by confusion, disagreement, a lack of trust, and a lack of incentives to keep partners engaged. Additional operational research is necessary to understand the best ways for moving forward given the challenges of multistakeholder partnerships for HSS.

DISCUSSION

This review serves as a background paper for the National Academies of Sciences, Engineering, and Medicine’s workshop on the Long-Term Picture for Health Systems: The Role of Public–Private Partnerships in Health Systems Strengthening. Based on the literature contained in this review, future iterations of PPPs involved in HSS could take the following actions to address key challenges experienced in the past:

1. Consult with national, district, and community stakeholders, in particular local health authorities, to identify health priorities and needs at each level.

2. Integrate key stakeholders in the partnership at the global and the country level who have technical skills in all the processes involved for HSS; for example, drug development, procurement, distribution, infrastructure, health workforce management, health care provision, monitoring and evaluation, health education, community buy-in, etc.
3. Explore shared values and establish an agreed-upon definition of the health system, on which partners can establish programmatic goals and objectives.
4. Precisely define and communicate the roles and responsibilities of each partner, including mutual accountabilities and lines of authority.
5. Consult regularly with all national, district, and community-level stakeholders to ensure program activities are in line with actual needs, and any unintended adverse consequences are addressed.
6. Define strategies for conflict resolution and joint decision making; communicate with partners regularly to keep everyone engaged.
7. Establish a timeline that is practical and manageable, and communicate this to all partners and relevant stakeholders.
8. Keep partners accountable by publicizing commitments and tracking progress regularly and transparently.
9. Establish a plan to ensure long-term financial sustainability, taking into account the costs associated with health care delivery in remote and rural areas, as well as rising costs associated with rising demand for services.
10. Collaborate with industry partners to ensure sustainability and affordability of drug supply.
11. Recruit, train, and maintain an adequate workforce to support the rise in demand for health care and supportive services.
12. Establish a plan for referral and health information systems to connect privately operated health facilities and government facilities.
13. Ensure adequate integration of national health programs and policies at privately operated health facilities, taking into account any additional resources or support necessary.
14. Support government health authorities to conduct regulation, monitoring, and quality assurance.
15. Support government stakeholders involved in baseline and routine data collection to ensure program monitoring and evaluation.
16. Ensure broader patient populations can benefit from laboratory resources established by disease-specific programs through national policies and funding support.

Noticibly absent from the literature is a critical examination of the incentives that motivate private-sector entities to join PPPs, especially PPPs that that seek to strengthen health systems (where the immediate benefit is harder to measure). Much skepticism exists in the public sector regarding industry incentives for participating in PPPs (Barr, 2007; Reich, 2000). The authors Buse and Tanaka acknowledged the importance of incentives by contending that values and interests must be understood in order to appeal to and maintain partners. Potential incentives for the private sector to participate in PPPs include networking opportunities, access to knowledge, exposure to best practices, and entrance into new markets. Buse and Tanaka, both from UNAIDS, suggest appealing to the private sector’s profit-oriented values and need for a “return on investment” (Buse and Tanaka, 2011). A question, however, remains: Why would private-sector entities participate in HSS activities where the return on investment is not immediate (and often difficult to measure)? Private-sector perspectives may address the skepticim of the global health and development communities and illuminate strategies to maintain successful PPPs.

Understanding public- and private-sector incentives is one step to understanding program sustainability; incentives are necessary to ensure partnerships last as long as it takes for health system goals to be met. Sustainability of health system achievements is also critical, but how do PPPs measure their impact on health systems? Unsurprisingly, literature on PPPs barely addresses sustainability of partnerships and achievements in HSS. Only two articles make general remarks on sustainability, suggesting PPPs establish flexible partnerships, long-term financing, and risk-management mechanisms to stand the test of time (Buse and Tanaka, 2011; Reich, 2000). Discussions at the workshop will be a useful first step in filling the literature gap on sustainability in PPPs for HSS.

CONCLUSION

Diagonal approaches to global health programming will allow a convergence to happen within the next two decades; thus, PPPs that continue to address disease priorities and strengthen health systems will help LMICs reduce mortality to the level of HICs by 2035. As public and private organizations become more active in pursuing HSS strategies, the workshop serves as an opportunity to examine new models of partnerships that account for sustainability, incentives, measuring performance, and addressing the key challenges experienced in the past. This literature review encourages PPP Forum members and the public audience to share experiences that fill gaps in the literature, and to discuss alternative

models for PPPs that meet the challenges of HSS and improve performance and outcomes going forward.

REFERENCES

Kaboru, B. B. 2012. Uncovering the potential of private providers’ involvement in health to strengthen comprehensive health systems: A discussion paper. Perspectives in Public Health 132(5):245-252.

Mackey, T. and B. Liang. 2012. Threats from emerging and re-emerging neglected tropical diseases (NTDs). Infection Ecology and Epidemiology 2:18667.

MMVnews. 2002. Peroxide potential for malaria. Geneva: Medicines for Malaria Venture.

Naimoli, J. F. 2009. Global Health partnerships in practice: Taking stock of the GAVI Alliance’s new investment in health systems strengthening. International Journal of Health Planning and Management 24(1):3-25.

Nkengasong, J. N., P. Nsubuga, O. Nwanyanwu, G. M. Gershy-Damet, G. Roscigno, M. Bulterys, B. Schoub, K. M. Decock, and D. Birx. 2010. Laboratory systems and services are critical in global health: Time to end the neglect? American Journal of Clinical Pathology 134:368-373.

Oluwole, D., and J. Kraemer. 2013. Innovative public–private partnership: a diagonal approach to combating women’s cancers in Africa. Bulletin of the World Health Organization 91:691-696.

Ravindran, T. K. S. 2010. Privatisation in reproductive health services in Pakistan: Three case studies. Reproductive Health Matters 18(36):13-24.

Reich, M. R. 2000. Public–private partnerships for public health. Nature Medicine 6:617-620.

Savigny, D. D., and T. Adam. 2009. Systems thinking for health systems strengthening. Geneva: World Health Organization.

Sturchio, J. L., and G. M. Cohen. 2012. How PEPFAR’s public–private partnerships achieved ambitious goals, from improving labs to strengthening supply chains. Health Affairs 31(7):1450-1458.

Vennerstrom, J. L., S. Arbe-Barnes, R. Brun, S. A. Charman, F. C. K. Chiu, J. Chollet, Y. Dong, A. Dorn, D. Hunziker, H. Matile, K. Mcintosh, M. Padmanilayam, J. S. Tomas, C. Scheurer, B. Scorneaux, Y. Tang, H. Urwyler, S. Wittlin, and W. N. Charman. 2004. Identification of an antimalarial synthetic trioxolane drug development candidate. Nature 430(7002):900-904.

WHO (World Health Organization) 2007. Everybody’s business: Strengthening health systems to improve health outcomes. Geneva: World Health Organization.

WHO. 2015a. Global health observatory data repository. http://apps.who.int/gho/data/?theme=home (accessed June 8, 2015).

WHO. 2015b. Kenya: WHO statistical profile. http://www.who.int/gho/countries/ken.pdf (accessed June 8, 2015).

WHO. 2015c. Trade, foreign policy, diplomacy and health: Public–private partnerships for health. http://www.who.int/trade/glossary/story077/en/ (accessed June 8, 2015).

Zicker, F. 2007. Impact of research on neglected diseases: The role of the Special Programme for Research and Training in Tropical Diseases (TDR). Salud Pública de México 49:301-305.

This page intentionally left blank.