Health Action International

Public-Private 'Partnerships'

Addressing Public Health Needs or Corporate Agendas?

Report on the HAI Europe/BUKO Pharma-Kampagne Seminar
3 November 2000

HAI Europe

Introduction

Lisa Hayes, Communications Director, HAI Europe

Today there is a fundamental shift in the way in which public health problems are being tackled. Due to a change in strategy, the World Health Organization (WHO) and other UN agencies now advocate so-called 'public-private partnerships' as the policy innovation of our time.

The private sector's immense resources make it an irresistible yet potentially overpowering 'partner' for public health initiatives. The economic power of this group is extraordinary. In fact, the five largest multinationals have revenues more than double the combined gross domestic product of the poorest 100 countries. [note 1]

For years, HAI and other public health advocates have worked to strengthen and support the WHO and its advocacy of rational drug use policies. Recently, they have become concerned about ramifications of private sector funding on the mission and standing of WHO and other public institutions involved in health policy. HAI and others have drawn attention to the fact that corporations cannot be held accountable in the same way that governments can. Ultimately, companies are accountable to their shareholders. Growing dependence on private sector funds could lead to many problems one of which is the problem of sustainability.

This seminar, co-organised by HAI Europe and BUKO Pharma-Kampagne, was held to evaluate the risks and benefits involved in public-private interactions and to find out why this trend towards partnership has developed and taken hold of the imagination of public agencies. In the opening presentation, Gill Walt traces the political and economic changes in the international landscape that have made the time so ripe for co-operation under the name of 'partnerships'. She explains that the private sector increasingly operates under a global spotlight and has been repeatedly criticised that its methods and outputs do little to meet public health needs. Working in 'partnership' with leading public health institutions at the international and national levels is certainly an effective way of countering that negative image.

In addition to the World Bank and a number of UN agencies, the pharmaceutical industry is actively lobbying to have partnerships be accepted as the way forward. As a press release from one of its trade groups stated "public-private partnerships are increasingly seen as the only viable means to solve intractable social and health problems, such as poverty and disease eradication, new drug research, access to medicines and improving drug quality...." [note 2]

While industry sees the advantages of working closely with WHO and other health 'partners', others suggest that such close association with industry could have negative effects for the health bodies involved and ultimately, the public interest. In her contribution, Judith Richter draws attention to 'partnerships' as part of a sophisticated corporate issues management plan that must be assessed in terms of context and power.

The need to also analyse industry's motivation is highlighted in Patti Rundall's presentation that underscores the fact that the ultimate goals of corporations and public health bodies and governments differ fundamentally. She calls on NGOs and governments to make sure they understand the stakes involved if and when they decide to enter into public-private dialogues or partnerships.

But assessing the trend towards public-private 'partnerships' is not only about having a closer look at their potentially underestimated risks. Public-private initiatives are said to address health problems affecting people. To date, HAI believes too little attention has been given to assessing how these initiatives affect the health and conditions of those they are meant to help. The question remains: Do their benefits justify their risks? As HAI stated at a meeting of the WHO Executive Board, "The most important question therefore is whether increased interaction with the commercial sector is a major way forward towards Health For All. WHO must be able to demonstrate that the poor directly benefit from more public-private partnerships. Acceptance of industry partnerships and industry sponsorship without strong, enforceable, accountable and transparent guidelines for these relationships will undermine and destroy the organisation's role, responsibility and reputation." [note 3]

Public-private initiatives can redirect national or international health policies and priorities. They can defeat crucial local or national efforts already underway such as essential drug programmes, generic drug production or vaccination programmes. As Anita Hardon points out in her presentation, for the private sector, such public-private collaborations cannot be seen in strictly altruistic terms. Rather, they are often an investment in promoting conditions that favour branded products and newer, more expensive drugs. Her presentation on developments in the field of vaccines raises serious questions about whose agenda is being followed and at what cost.

Some participants at the seminar pointed out that they were not against co-operation between public and private actors per se. In discussion, examples of successful, focused projects aiding access to medicines or addressing a local health problem were mentioned. However, most agreed that there are huge differences in the quality, sustainability and power relationships of the types of co-operation now all being labelled as 'partnerships.' That fact that HAI Europe and many of its network contacts see the value of specific joint actions does not mean that the most varied types of public-private ventures should all be labelled 'partnerships' or should be assumed to improve public health.

While the commercial parties are quick to publicise the funding support given to public projects, they are often less forthcoming on other aspects of the initiative. For example, sometimes there is little explanation given about local stakeholder involvement in the development, implementation and evaluation of such projects. Often recipient governments, NGOs and communities have little say in how the initiatives are organised and they can be marginalised in the decision-making processes that affect them. Given the imbalance of power between providers and recipients, there is a need to examine if many of the projects have real, lasting benefits for the recipients. One organisation that has been trying to address that very concern is the GTZ, a close collaborator with the German Ministry of Economic Co-operation and Development. During the seminar, Kordula Schulz-Asche of GTZ outlined the steps it followed to determine the best chance of achieving success in a public-private venture aimed at reducing mother-to-child transmission of HIV/AIDS. It is clear from her description of the interplay of agendas, possibilities and constraints that mere political commitment to address a health emergency is not enough to make a sustainable impact on the problem.

While public-private ventures grow in number, very few receive attention after their initial launch. Once the flurry of news articles announcing the initiative and lauding the company have stopped, few initiatives are actually assessed to determine their effects on local populations and public health achievements. This seminar's goal was to open the debate on public-private interactions and determine some of the key issues that need to be more thoroughly examined by NGOs, public officials and health organisations before such joint initiatives become an unstoppable and perhaps, ultimately harmful, trend. There are many questions that need to be asked, and more importantly, to be answered. Critical analysis of the long-term health consequences caused by such public-private ventures is necessary. NGOs have a role to play in ensuring that sustainable, responsible solutions are put forward that meet public health needs and not just corporate agendas.

HAI believes too little attention has been given to assessing how these initiatives affect the health and conditions of those they are meant to help.

Opening of the seminar

Seminar chair, Charles Medawar, Social Audit, UK

Opening the seminar, Medawar emphasised the complexities of the topic, many resulting from ambiguities and uncertainties of definitions. He said the day's discussion would be aimed at unravelling both the common threads and the differences in many kinds of arrangements that might be described as public-private 'partnerships'. The chair put forward some provocative questions to start the day. He asked the participants to debate whether or not such 'partnerships' are fair for all parties involved and actually in the best interest of public health. He also questioned who defines the needs to be addressed, and how.

Using private money for public health: the growing trend towards partnership

Gill Walt, Reader in Health Policy, Department of Public Health and Policy, London School of Hygiene and Tropical Medicine

Walt's presentation outlined the history and development of public-private 'partnerships'. Her goal was to define clearly public-private partnerships, explain why there has been a shift towards this type of co-operation and to question if they are ultimately good for public health.

The landscape of public health is changing before our eyes, and we, therefore, need to change our own mindsets. We have to accept that there is a change. The new millennium has brought the power of multinational corporations to the forefront.

What is partnership?
The name itself means different things to different people. Partnerships depend on agreement about key principles according to ethical guidelines. However, many purported partnerships do not fit this definition because of basic inequalities in the relationship. Partners often bring different levels of power to the interaction. Many times they are not able to call upon the same level of financial resources or expertise. So there exist different levels of influence. Sometimes the partners' roles change during the relationship's course. For these reasons, partnerships are dynamic but inherently unstable.

There are different kinds of 'partnerships' and it is important not to place them all within one group. The main categories include country-level co-operation between a public body and a private sector one and those occurring on a global level between, for example, United Nations organisations and commercial enterprises or their representatives.

There are three main types of partnerships:

Product development partnerships initiated by the public sector in response to market failure
Systems/issues partnerships such as the Roll Back Malaria initiative, which involves co-ordination of different groups and
Product-based partnerships such as donation programmes which are most often initiated by the private sector.

The types of partnerships being pursued have changed over time. For example, in the 1970's there was a stand-off between the public and private sectors which resulted in a separation of their activities. The political climate of the time ruled out any possibilities of partnership and instead there was a feeling of hostility, antagonism and conflict between the two. In the 1980's the private sector began to expand and gain influence. Public sector institutions began holding discussions with commercial enterprises, though often in secret. Most recently, the 1990's have ushered in an era in which the private sector has grown dramatically. This has encouraged governments and international organisations to work much more closely with industry and civil society in an effort to achieve health goals.

Why partnerships?
The shift towards public-private partnerships on health is the result of increased global integration due to:

• The scope and pace of goods moving across borders
• The lack of geographical boundaries for infectious diseases
• The increased possibility for rapid communication (Internet)
• The spread of ideas
• World-wide products and marketing

These developments have reduced state sovereignty. Decreasing government control means that there is a growing need to collaborate with the strong, corporate sector.

Today companies are moving away from simply selling products to selling a brand image. Partnerships can help identify a certain product or company with a well-known public health organisation or ideal. At the same time, there is greater scrutiny of corporate activity. Globalisation has caused a fundamental change in how institutional arrangements are made, how power is exercised and ultimately, how decisions are made.

There has also been an ideological shift. Even those who are strongly pro-market accept that there are market failures that significantly affect public health although there is uncertainty about how to deal with such failures. There is disillusion with the UN. Concerns have been voiced regarding its effectiveness, inter-agency competition and bureaucracy. Moreover, there is disappointment with governments due to corruption, sluggish response time and the overwhelming desire to avoid risk.

Changing markets, technologies and attitudes have heightened awareness of the interdependence of actors involved in public health. Production has become more costly and this has resulted in the empowerment of industry. Industry's current powerful stance has emboldened it to demand that it be a partner in discussions on public health. Today, this request is hard to deny.

Why are partnerships viewed as such an interesting option for those involved? UN agencies and bilateral donors see them as an opportunity to achieve public health goals by harnessing private funds. The second stakeholder, industry, can achieve even more gains. First, it is a chance to increase its influence in the global arena. It can also bring about direct financial benefits. And lastly, it is an excellent way to carry out brand and image promotion.

However, questions remain: Do partnerships bring about a win-win situation for all those involved? Can the private sector really have a health goal? Due to the fact that it is profit-oriented, such a goal is rarely central to its mission. Still, can public and private goals be reconciled? Differences remain in what they are trying to achieve. There is potential for a conflict of interest in these goals.

Key concerns
Partnerships present a number of key concerns:

Representation/legitimacy: Those designated to benefit from such public-private partnerships rarely sit on these projects' Boards of Directors. They are also usually uninvolved in the planning or agenda setting. This raises real concerns about the representation of their needs and interests in any such partnership endeavour. This is in striking contrast to the representation available to countries through usual UN representation.

Accountability: Who is actually accountable for the outcomes of such partnerships? Is it shareholders, board members, or donors? To whom are public-private partnerships accountable? Does accountability have to be shown to the Board or to the people the partnership is meant to help? We need much more information about how these partnerships are actually being carried out in countries.

Inequity: Public-private partnerships may also undermine equity within and between countries. Often countries will not be selected for participation if, for example, they are unstable or highly populated or considered 'difficult'. Instead, other countries will receive attention. While this is understandable, it remains unfair.

Another influence skewing equity is the fact that many public-private partnerships address specific infectious diseases, not health delivery systems. The huge amounts of money pumped into some initiatives can also lead to a further shift in the public health agenda. How much of a voice does the World Health Organization have in setting priorities for world health with its budget of approximately US$1 billion, when the Global Alliance on Vaccines Initiative (GAVI) has US$1 billion just for vaccines and the Bill and Melinda Gates Foundation is spending well over US$6 billion on infectious diseases?

Threats or opportunities?
Global health problems demand global solutions, but little is known about the effectiveness of partnerships. There is a lack of transparency in how they operate and what they achieve. There is also the potential that they will divert attention away from other crucial areas of concern.

More evidence is needed on which situations can best be met through partnerships, and which need to be the responsibility of government or the public sector. Much also needs to be learned about governance issues at the global level and delivery at country and local level.

'Partnerships' between UN agencies and transnational companies: A critical perspective

Judith Richter, consultant on the politics of health

Richter reminded the audience about the importance of examining issues from a perspective of context and power. She said one has to look at today's public-private ventures in light of the political developments of the past thirty years. In her presentation, she highlighted the need to analyse so-called public-private partnerships also as part of a sophisticated corporate issues management plan aimed at advancing the political and economic agenda of transnational (TNC) corporations. An unquestioning rush on the part of many governments, UN agencies and some NGOs to join such 'partnerships' may ultimately damage public interests, she argues.

'Public-private partnerships' (PPPs) are being promoted as the policy innovation of the turn of the millennium. Much of the predominant PPP discourse depicts past heated controversies over, for example, the establishment of a socially just New International Economic Order and for international regulation of transnational corporations as purely ideology-driven, polemic debates. Today, we are being called upon to give up what is depicted as an unreasonably distrustful attitude towards wealthy, powerful corporations. We are being told that this distrustful attitude is depriving the world of valuable benefits to be expected from closer, more trusting interaction with big corporations, such as new drugs and vaccines for the poor or community health programmes. This is a naïve representation of a complex issue. There are significant gaps in the PPP discourse. Crucial questions, which are not being asked, include the following:

1. Why are big corporations interested in 'partnerships' with UN agencies?
The drive towards PPPs is usually explained by corporations' heightened sense of responsibility. On closer scrutiny, however, much of the corporate drive towards closer interaction with UN agencies could as much be attributed to their 'enlightened self-interest', a strategic trading of part of their short-term profits in anticipation of increased long-term profits.

Not only corporate public relations professionals but also institutions such as the World Bank have advised corporate managers to engage in 'partnerships' with reputable institutions and individuals in order to 'build trust'. Trust, in turn, is advertised as the basis for improved corporate 'bottom-line performance' and 'risk management'.

Close association with the UN and NGOs can, for example, enhance the reputation of corporations through 'image transfer', irrespective of their actual practices. A good image can be of advantage in a competitive market. It is also a political resource. Corporations want to be seen as 'good corporate citizens'. They know that this might well translate into enhanced political legitimacy and influence.

It is no secret that companies want to have a greater role in shaping global policies. When then Nestlé CEO Helmut Maucher took the helm of the International Chamber of Commerce (ICC) in 1997, he said in a Financial Times editorial entitled "Ruling by Consent":

Governments have to understand that business is not just another pressure group but a resource that will help them set the right rules. The International Chamber of Commerce […] is the obvious partner from the business side for this intensified dialogue with governments. With its long established links with the UN-system, the WTO [World Trade Organization] and other intergovernmental organisations it is uniquely placed to make the business viewpoint heard in the decision-making bodies that count in today's world. (Maucher 1997)

A year later, Maucher announced in the same newspaper:

We have established the ICC as the preferred dialogue partner for business with the United Nations and other international institutions. (quoted in Williams 1998)

Citizen groups have raised concern that UN agencies' lack of precautions with respect to their 'partnerships' with transnational corporations is being used by a number of corporations to 'bluewash' their image. Partnerships with the UN can be too easily used to cleanse tarnished TNC reputations through close association with the United Nation's blue flag and logo. (TRAC 2000)

2. Where does the corporate money come from?
This is the other conspicuously absent question from the dominant PPP discourse. Screening for the ways in which corporations have accumulated their wealth is done in a very unsystematic and non-public manner, if at all. The PPP discourse also does not mention that those transnational corporations that are offering donations to public institutions are often the very same corporations that have successfully lobbied for global tax restructuring. This has resulted in a redistribution of the world's wealth from the poor to the rich and the erosion of states' capacities to provide for public services.

Is there truly such a need for public display of gratitude if winners of global economic restructuring, such as Microsoft's Bill Gates who earns US$120 million a day (UNDP 1999), donate a few hundred million dollars? With his estimated total assets of US$63 billion (Forbes 2000), Bill Gates alone could finance the World Health Organization for thirty years. Unasked also remain the questions of what price is being paid for corporate funds and whether the necessary funds for public services could not be collected in other ways.

3. Why do the most varied kinds of interactions with industry have to be called 'partnerships'?
In fact, many of the interactions, which are currently promoted as public-private partnerships, are not new. What is new is the name and the way in which governments, UN agencies and NGOs are rushing into them. What is also new is the extent to which safeguards for public interest-based policy-making and scientific standard-setting are being ignored.

The subsuming of the most varied interactions between the public sector and the for-profit sector under the term 'partnership' has two major consequences:

First, it obfuscates the nature of the relationship. For example, many of the current 'public-private partnerships' are nothing but corporate sponsorship in cash or in kind or negotiations for favourable drug prices; others are semi-private discussions between public institutions or high-level political figures and big corporations; others are publicly- subsidised research collaborations. (In business language some of the PPPs are actually called 'strategic sponsorship' or lobby activities).

Also obfuscated is the fact that the potential and pitfalls of various types of interactions between the public and the commercial sector have often already been discussed under various other, more precise terms (for example, there are extensive discussions about the disadvantages of donation-driven policy-making).

Little discussed is a type of public-for-profit sector interaction which was hitherto seen as problematic in democratic societies: a new development in the name of 'partnership' is the ready acceptance of corporate participation in public policy-making, respectively UN attendance of corporate fora. The International Chamber of Commerce, for instance, invites government and UN leaders to private business events such as their World Economic Summit held in Davos, Switzerland each year. One result has been the Global Compact, which was announced as a partnership initiative between the UN General Secretary and the ICC without any public discussion on the desirability of such an initiative or its possible consequences. Business leaders have also used their close relationship with the UN to press for a distinction between 'reasonable' and 'confrontational' NGOs. They have questioned the public funding of those NGOs which business labels as confrontational.

The second problem is that the term 'partnership' is heavily value-laden. It gives the impression of equality and suggests that all sides are working for a joint goal. The positive connotation of public-private partnerships is no oversight. Indeed, two other value-laden terms are usually cited as main criteria for engaging in 'partnerships' with corporations and their business associations, namely 'trust' and 'mutual benefits'. Both the name and these criteria interfere with unprejudiced evaluations of whether or not these interactions are indeed beneficial for society. The measuring stick for engaging with corporations must remain the contribution of the venture to the promotion of public interests. It cannot be a question of trading some public interests against profit for the corporate participant.

4. What are the societal risks of 'public-private partnerships'?
The broad societal risks involved in 'public-private partnerships' remain underexplored. There is too little debate about the risk of transnational corporations setting global political agendas. Some of the alliances may provide corporations with easy access to market and political intelligence. The general trend towards PPPs can also lead to censorship by and self-censorship within the UN, government or NGO counterpart and an overly optimistic depiction of transnational corporations' actual practices. It can result in 'institutional capture' in which the non-corporate partner is instrumentalised for a company's or business association's aims. Public-private partnerships risk weakening the key drivers of corporate 'responsibility', namely binding regulation, collective bargaining and more radical forms of social activism. (Utting 2000; Richter 2001)

Recommendations for action
To begin addressing the problems mentioned, a number of steps should be taken:

• The word 'partnership' should be replaced with terms that more accurately describe the respective relationship. Moreover, blind 'trust' should be replaced by lucid analysis and transparency, and the criterion 'mutual benefit' should be replaced with 'benefits to society'.
• Guidelines on conflict of interest and clear baseline criteria need to be drawn up for each type of interaction to ensure that these public-private interactions truly serve the public interest.
• Public-private ventures must be based on contractual agreements, which are placed in the public arena. A clause should ensure the termination of the contract and the possibility of negative publicity if corporations do not uphold their contractual agreement.
• The UN should re-establish a centre along the lines of the UN Centre on Transnational Corporations that would provide for public data on the structure and practices of transnational corporations.

It is time to see where 'public-private partnerships' have brought us. There should be a moratorium on them. A public assessment of past 'partnerships' should be conducted to assess if the poor have benefited from them, and if other alternatives could have provided better public health and policy outcomes, at less cost. This should include the examination of how states can withstand corporate pressure for undue tax cuts and public subsidies to the commercial sector. Finally, public debates about the legitimacy of corporations shaping the world's policies should be promoted at all levels.

References:
Forbes (2000) "Forbes 400 richest in America". www.forbes.com/400 richest/, accessed 8 March 2001.
Maucher (1997) "Ruling by consent: Nestlé chairman, Helmut O. Maucher, urges governments to work with business to establish the framework for the global economy". Financial Times, 11 December.
Richter, J. (forthcoming 2001) Holding corporations accountable: Corporate conduct, international codes and citizen action. London/New Jersey: Zed Books.
TRAC (2000) "Tangled up in blue: Corporate partnerships in the United Nations". San Francisco: Transnational Resource & Action Centre (TRAC).
UNDP (1999) Human Development Report: Globalization with a human face. New York/Oxford: Oxford University Press.
Utting, P. (2000) "Business responsibility for sustainable development". Geneva: United Nations Research Institute for Social Development (UNRISD).
Williams, F. (1998) "The voice of business heard around the world: How outgoing president Helmut Maucher got global institutions listening to the once fusty International Chamber of Commerce". Financial Times, 29 December.

A Case for Partnership? The German Government/Boehringer Ingelheim initiative on HIV/AIDS

by Kordula Schulz-Asche, team member of the Sector Project AIDS Control in Developing Countries, German Society for Technical Co-operation (GTZ)

The German government is weighing the possibilities of public-private ventures on priority health issues such as HIV/AIDS. Kordula Schulz-Asche, a team member of the GTZ AIDS Sector Project, presented a study realised on behalf of the German government to define the prerequisites for donated supplies of the drug nevirapine to reduce mother-to-child transmission of HIV/AIDS, especially in Sub-Saharan Africa. In her overview, she described why the government decided to participate in this effort and the framework of the technical co-operation in the fight against HIV/AIDS in developing countries, including the importance of prevention strategies and partnerships.

The HIV/AIDS epidemic is unique in its devastating impact on the social, economic and demographic underpinnings of development. We know that countries that have adopted forward-looking strategies to fight it are now reaping the rewards in the form of falling rates of incidence. (This has been found in AIDS prevention programmes supported by the German government in Western Uganda and Tanzania.)

GTZ works on behalf of the German Ministry of Economic Co-operation and Development (BMZ) to spearhead efforts to combat HIV/AIDS. Since 1987, the Sector Project has aimed to enhance the capacity of national and local governments and the private sector to cope with the epidemic using a comprehensive approach to AIDS prevention.

In its fifteen years of experience in this field, GTZ has gained important insights on what brings about effective responses to HIV/AIDS interventions. These include:

• A nationally driven agenda with continuing engagement at the highest levels of government
• A national AIDS plan involving a wide range of actors, including the private sector
• Social openness, increasing the visibility of the epidemic and countering stigma
• Social policies that address core vulnerabilities
• The involvement of all sectors, not just health
• A recognition of the synergy between prevention and care
• Support for community participation
• Targeting interventions at the most vulnerable groups in society.

Today German technical co-operation follows both a national and international agenda and is actively involved in regional partnerships on HIV/AIDS with UNAIDS and other actors. On behalf of the Ministry, GTZ's interventions, mostly focusing on prevention efforts, occur at different levels:

• The international and regional level (e.g. UNAIDS)
• Through bilateral AIDS prevention projects
• Through the integration of HIV/AIDS prevention components in bilateral basic health and reproductive health projects
• Through the integration of HIV/AIDS prevention components and activities in all projects
• In prevention programmes for the staff of partner organisations (Ministries, NGOs, expatriates and local staff) and
• Social marketing of condoms (including information, accessibility, and quality factors).

German development policy and public-private collaborations
At the moment, there are not so many German government experiences with public-private ventures to fight AIDS besides collaborations in the field of social marketing of condoms. An interesting field of co-operation has been identified in the technical support of HIV/AIDS prevention programmes for the employees of German corporations in developing countries, as in preparation with Daimler-Chrysler South Africa. The technical support (financed by the corporation) provides information, counselling and HIV/AIDS-related health services to employees of the firm.

Public-private ventures and drug donations: the answer?
Today more than half a million pregnant women live with HIV/AIDS. Ninety percent of them lives in Sub-Saharan Africa (UNAIDS estimation). The assumed HIV transmission rate from mother-to-child (in utero and perinatal) is 25% - 45%. At the same time, recent studies suggest that a single dose of the drug nevirapine reduces the risk of mother-to-child transmission to approximately 13% (HIVNET).

The German pharmaceutical firm, Boehringer Ingelheim, announced in June 2000 that it would donate supplies of nevirapine for five years to developing countries. To be eligible, countries must have a national AIDS policy (UNAIDS/WHO), high participation of pregnant women in maternal health care services and an existing HIV/AIDS prevention programme. The donation programme works through governments and is implemented in hospitals with counselling and qualified staff. The quantity of nevirapine to be shipped to each country would be in accordance with the estimated number of HIV-positive women. The company made it clear it would not be responsible for local distribution of the drug or training of health personnel.

Against that backdrop, the German government asked GTZ to study in collaboration with Boehringer Ingelheim, the possibilities of prevention of mother-to-child transmission (PMTCT) programmes in the framework of German development policy.

A number of scenarios were drawn up involving varying levels of intervention. The goals, necessary activities and costs were set out for each one. Ultimately, Kenya, Uganda and Tanzania were selected because of established bilateral co-operation. After discussions with the bilateral partners, the study proposes:

In Kenya, 1,500 pregnant women in the GTZ-supported district of Migori and Kuri (Western Kenya) take part. Here the HIV prevalence is approximately 26%. The proposed intervention includes HIV counselling and testing, nevirapine and breastmilk substitutes distributed from two hospitals. The costs, without long-term therapy, are estimated at DM 1.2 million (US$550,000) in three years.

In Uganda, 8,000 pregnant women living in the GTZ-supported Kabarole district in the western part of the country could be involved. This region has an HIV prevalence rate of around 20%. The possible interventions include: HIV counselling and testing, supplies of nevirapine and breastmilk substitutes, plus long-term antiretroviral therapy (if possible) through two hospitals and one health centre. The costs are approximately DM 2.5 million (US$1.2 million) in three years, without long-term therapy.

In Tanzania, 8,000 pregnant women could be involved in the GTZ-supported AIDS prevention programme area in the Mbeya region. Here HIV prevalence is about 15%. The intervention could comprise: HIV counselling and testing, supplies of nevirapine, treatment of opportunistic infections and psycho-social support, carried out in two hospitals and one health centre. The costs, excluding long-term therapy, are estimated at DM 2.2 million (US$1 million) in three years.

In total, the project would assist 52,000 pregnant women. The total implementation costs are approximately DM 6 million (US$2.8 million), including the costs for nevirapine which are estimated at DM 0.069 million (US$32,000).

The relationship of public and private funding in this case study shows that the drug donation alone cannot establish a partnership in the proper sense. Further engagement of the private partner would be necessary. In closing, one personal point of view: there is a risk that funds for effective prevention programmes will be more and more diverted towards therapy approaches.

Vaccination Policy and the Public-Private Mix

Anita Hardon, Medical Anthropology Unit, University of Amsterdam

Global vaccine efforts led by UN agencies have slowly given way to more donor-appealing initiatives led by private foundations. This shift in public health policy is already affecting how money is being spent on vaccines. Greater involvement by the research-based industry and private charities has promoted new, more hi-tech medicines against more diseases. At the same time, up to 25% of children in many developing countries still receive no vaccinations. In her presentation, Anita Hardon, traces how donor-driven projects have started to weaken the role played by long-standing public bodies, national governments and local industry. She also raises concerns about how today's vaccine campaigns leave little room for voices from the South and consumers.

Vaccination programmes are critically important for public health. They are also extremely appealing to donors. When one considers the reason why, the various aspects of vaccines make the answer clear: By supporting such initiatives one can change the world, eradicate a disease, make war against viruses and sign your name on the cure.

In the past, donors supported vaccine programmes for a number of reasons, including:

• prevention is better than cure
• vaccines are a cost-effective intervention
• contributing to the eradication of disease
• delivering a "magic bullet" cure
• the ease of delivery, and
• no compliance problems.

Progress on immunisation over time
In 1974, WHO expanded its public health programme called the Expanded Immunization Program (EPI). In 1978 the importance of vaccines was included in the declaration released on the Alma Ata Conference. A few years later, in 1984, the Child Survival Taskforce was created, this was an early public-private partnership. The taskforce made an effort to increase vaccinations through the Universal Coverage of Immunization (UCI) campaign. UNICEF declared the reaching of UCI, i.e. 80% coverage of the world's children, in 1990. Following this achievement, the 1990's ushered in an era of donor fatigue and decreasing vaccination coverage rates in many developing countries.

In the 1990's, three new vaccine campaigns were introduced. Firstly, there was a move to eradicate polio backed by huge private funding (US$400 million was donated). This private money skewed regular public services as EPI's regularly scheduled national immunisation days were interrupted by new polio vaccine drives. The second campaign involved the introduction of user fees in the Vaccine Independent Initiative sponsored by UNICEF. With this change in policy, UNICEF announced its belief that some countries should start paying for their own vaccines. The third campaign was the 'magic bullet' approach which promoted new and improved vaccines financed by private foundations in the so-called "Childhood Vaccination Initiative (CVI). The CVI was created in 1997 to solve the sustainability problem faced by many vaccine initiatives. Global industry and public monies worked together within its programme. The emphasis was placed on development and products instead of health systems. A year later, the CVI was damaged by donor tensions and concerns about the weakening of the UN system. Commercial interests started to dominate CVI. The programme itself received criticism for focusing on technical solutions.

Industry's interest in vaccines: magic bullets
Today vaccination policies seem to have shifted towards public-private 'partnerships' and away from equity. The Director General of the WHO has come out strongly in favour of public-private ventures to treat infectious diseases. Health has become an economic asset and is no longer primarily seen as a basic human right. In vaccination programmes the focus now appears to be creating markets for new vaccines Achieving equity in access to a limited number of essential vaccines, the objective of the EPI does not seem to be the primary objective any more. The notion of market failure and the lack of new vaccines are attractive ideas for the pharmaceutical industry as it can play a leading role in 'supporting' the development of new vaccines.

Industry is keen to develop new vaccines, although only an estimated 74% of the world's children are covered by current vaccine programmes [note 4]. The population already reached by vaccination programmes is a huge potential market for new vaccines and there is more profit in it than in trying to reach the remaining 30%-40% that currently receives no vaccines. (The 74% figure hides the fact that some countries still have only 40% coverage.) Pharmaceutical companies want to expand the number of vaccines included in the EPI. Currently, six generic antigens are used in it. Sixty percent of the vaccines are produced locally so an inexpensive generic alternative is available and used. Now companies and donors are looking for new magic bullets - new vaccines - that will prevent more diseases. Such an approach is much more attractive to donors than working to reach the children still not receiving the basic mix of vaccines.

New vaccine campaigns
Since the beginning of 2000, there have been three new approaches to address vaccines:

• The Global Alliance for Vaccines and Immunizations (GAVI, largely supported by the Bill & Melinda Gates Foundation)
• The Children's Vaccine Programme (CVP, also funded by the Gates Foundation)
• UNICEF's Global Fund for Kids Vaccines (GFKV)

These initiatives have overlapping goals. The Gates Foundation has donated hundreds of millions of dollars towards the first two funds for a five-year period. (Interestingly, this support will be facilitated by the NGO PATH, which coincidentally happens to be based in Seattle, near the headquarters of Gates' company, Microsoft.) Unlike earlier vaccine campaigns, these initiatives spend little time discussing sustainability. Instead there is a great deal of talk about the need to create new systems and new vaccines. Critics have raised concerns that these private initiatives reduce local capacity to produce vaccines. The fact that GAVI and the other programmes will work with newly developed vaccines generated by multinational firms could cause people to believe that locally produced vaccines have lower quality. It is also important to note that in initial disbursements of GAVI only 10% goes towards health systems support. Ninety percent goes towards new vaccines such as hepatitis B. This may change in the future, but it is indicative of the emphasis of support to vaccination programmes.

GAVI is an interesting case study to analyse. One can see where its financial support comes from, but who runs its Board? At present, its Board comprises some of the most influential international actors involved in public health today. The current members include four renewable members [note 5]:

• The Bill and Melinda Gates Foundation
• UNICEF
• The World Bank Group
• WHO

In addition, it has eleven rotating members which include various stakeholders:

• Three Northern (OECD) governments (Canada, The Netherlands, Norway)
• Two developing country governments (Bhutan, Mali)
• One OECD industry (Aventis Pasteur)
• One developing country industry (Center for Genetic Engineering and Biotechnology (CIGB))
• One foundation (The Rockefeller Foundation)
• One NGO (PATH /Bill & Melinda Gates Children's Vaccine Programme)
• One research institute (US National Institutes of Health (NIH))
• One technical health institute (US Centers for Disease Control)

Such a large initiative involves benefits and risks. GAVI's advantages include the increased resources brought to the vaccine issue and and its cost-effectiveness. Some of the initiative's negative consequences include the reinforcement of donor dependence, a skewing of health programmes, a large emphasis on creating markets, the weakening of UNICEF's independence, a lack of sustainability for traditional vaccines suppliers and technical transfer, greatly reduced transparency, and limited involvement by developing countries and consumers. One has to wonder what will happen to this initiative after its five years of funding has been used.

There is a great need for more consumer voices to be heard on this issue. Vaccination policy has changed rapidly during the past few years and consumer input has been lacking. We must start asking critical questions about such public-private interactions to ascertain the long-term consequences for public health. In such a high-profile area as vaccines, participants including donors, governments, and industry have a clear vested interest. Consumer voices need to make sure that the public health interest is represented as well.

The Perils of Public-Private Partnerships: How do partnerships impact grassroots campaigns?

Patti Rundall, Policy Director, Baby Milk Action UK and member of the International Baby Food Action Network (IBFAN)

The contrast of resources between corporations and NGOs is huge, as are their ultimate goals. In her contribution summarised below, Rundall draws examples from the world of breast milk substitutes sales and breastfeeding advocacy to suggest why corporations enter public-private ventures and the repercussions such co-operation can have on other stakeholders and public health.

The aim of Baby Milk Action is to save infant lives and end the avoidable suffering caused by inappropriate infant feeding by supporting the implementation of independent, transparent and enforced controls on the marketing of baby food. In contrast, the aim of Nestlé (a company which manufactures breast milk substitutes) is to participate in industrial, commercial and financial enterprises in Switzerland and abroad, particularly in the food and related industries. When we talk about 'partnerships' we must first be very clear about the objectives of companies. We cannot escape the fact that all corporations have a fiduciary (legal) duty to maximise profit for their shareholders. No matter what the rhetoric, and the often good intentions of individuals working within corporations, there has to be a financial payoff-either in the short or long-term.

One must consider: What is sponsorship? It is not a philanthropic gift. It is a commercial deal. Sponsorship is a payment by a business firm for the purpose of promoting its name, products or services.

The size of the corporations involved in sponsorship is a key issue. The question is: Where is the balance of power? WHO's annual spending is US$1.7 billion whereas Nestlé's annual spending on product promotion alone is estimated to be US$7 billion. This relationship is something to keep in mind when one talks about corporate generosity.

A number of pharmaceutical companies also manufacture breast milk substitutes and products closely related to artificial feeding. Many are now promoting 'medicalised foods' and medicalised solutions to normal feeding occurrences-using health claims and other strategies.

Since 1981, the International Baby Food Action Network (IBFAN) has worked to ensure that the International Code on the Marketing of Breast Milk Substitutes (and the eight subsequent WHA resolutions) are implemented, monitored and adhered to in every country in the world. IBFAN works to ensure that mothers and infants world-wide are effectively represented wherever decisions affecting infant feeding are made.

IBFAN's campaigns, involving Code training courses, networking, work on maternity legislation, emergency relief, HIV and activities such as the Nestlé Boycott, have focused on long-lasting effective controls. Because we have refused to be sidetracked into working 'with' individual companies, for example, into helping them to improve their own voluntary codes, we have not lost sight of our long-term objectives. To date, more than 116 countries (including India, China, Brazil and Nigeria) have taken action to implement the International Code and over half the world's population now lives in countries where laws are in place which broadly incorporate its main tenets.

The Code does not try to stop the availability or sale of breast milk substitutes, but it does seek to prohibit activities which persuade people to use them and to ensure that decisions about infant feeding are made on the basis of truly independent health advice. If water is not clean, a mother needs to know. When deciding whether or not to breastfeed, she also needs sound information about the natural immunity found in mother's milk and its role in preventing illness and death.

IBFAN has encountered problems with TNC/NGO partnerships. These problems are rarely publicised or acknowledged because they involve wider concerns relating to the very poor who, all too often, have no say in the decisions taken on their behalf.

For companies, the advantages of partnerships with prestigious NGOs are clear:

• They help produce an ethical image. Public relations companies now openly advise companies facing criticism to adopt 'cause-related marketing' strategies.
• Companies can aggressively advertise their links with charities and good causes in order to counterbalance bad publicity.

As one advertising executive stated "The benefits of cause-related marketing are long term...You are building a surplus account for the times when you have a crisis". [note 6]

The real danger comes when we try to identify and recognise the factors that affect poverty and ways to combat it. When partnerships with TNCs are proposed there is a danger that the 'wrong people' (people whose main objective has nothing to do with health - indeed whose goals conflict with the objective of health for all) are invited to be involved in 'research' and 'analysis'. As a result, the wrong questions are asked, or given priority, and the wrong solutions are proposed.

As an example, companies with a vested interest in the HIV and infant feeding market - the pharmaceutical and baby food companies - are pushing the UN to allow them to enter into 'partnerships' to help address the growing HIV/AIDS crisis. At the same time, the baby milk industry is promoting donations of formula and the use of artificial feeding as the 'simple' solution to the problem of HIV transmission. IBFAN is calling for much more caution and a clear perspective on the relative risks. While 1.7 million babies might have contracted HIV through breast milk in the last twenty years, almost certainly 30 million will have died from the replacement of breastfeeding by artificial feeding in the same time.

This case demonstrates how industry involvement can distort health policies and public perceptions of them and can result in the following risks:

• Censorship
• Control of research
• The provision of medical solutions without addressing primary preventions
• A focus on product procurement
• Labelling breastfeeding as the cause of the problem
• Focusing exclusively on the child, while forgetting the mother
• Showing artificial feeding as safe
• Suggesting that not providing alternatives (artificial food) is unethical
• Professing that 'partnerships' are the only solution
• Having the costs borne by families while the health care system is forgotten.

Today the stakes are high. NGOs have to see many public-private ventures for what they are and analyse their consequences for health. NGO representatives also need to consider their own actions in such deals. The little details matter. When you sit at the table it implies that you agree with the process. NGOs don't need to refuse the situation but they also don't have to accept it on industry's terms. It is important to demand transparency whenever an NGO, government or institution enters dialogue with industry or co-operates with it. Without it, you can easily lose your integrity and control.

Hidden Price Tags

Alain Guilloux, Médecins Sans Frontières (MSF)

For the last few years, MSF has mounted a public campaign to increase access to essential drugs. As part of this effort, it explored various means used by the pharmaceutical industry to address this problem. During the seminar, Guilloux questioned if one of industry's favourite responses, drug donations, was actually the most effective way to improve access. Below, he highlights findings from the MSF report he authored on this issue called Hidden Price Tags.

Pharmaceutical companies have no tax incentive to reduce the prices of their medicines. However, public opinion and health crises often call for industry action to help increase access. As a consequence, companies often decide to donate drugs in order to assist access and to help combat diseases. MSF has raised a number of concerns associated with this action including:

• What do drug donations cost the public sector in donor countries?
• Are donations a rational use of taxpayers' money?
• Are there incentives to reduce prices for the least developed countries?

MSF believes public funds should be used as rationally as possible to address the access crisis that exists in many parts of the world. To determine the best ways to increase access, MSF undertook a study of various methods now being used to reduce drug prices. The study examined the US situation and considered five models:

1. Using public funds to buy the least expensive generic drug on the world market
2. A pharmaceutical company donates for a specific disease programme
3. A company sells a small proportion of the drug at full price and donates the rest (concessionary pricing)
4. The company offers the drug at a discount to a developing country (differential pricing)
5. The pharmaceutical company matches the price of the lowest priced generic.

The study's results suggest that in most cases the two most expensive models for the US taxpayer are drug donations and concessionary pricing. Differential pricing was found to be the least expensive option for the taxpayer. The purchase of generics was also inexpensive.

On occasion, MSF has urged companies to donate drugs to help critically ill people quickly. However, the organisation realises that, on the longer-term, donations raise a number of problems. To begin, they only provide a short-term solution. It is not a sustainable model. While short-term action can temporarily relieve some access problems, it does not address long-term needs. Such donation programmes run into foreseeable long-term constraints, such as:

• Geographic restrictions
• Quantitative restrictions (only a limited amount of the drug is made available)
• Indication restrictions
• Time restrictions
• Delays (between the time the donation is announced and the actual drug reaches the user).

Drug donations also tend to distort rational drug use and hamper the growth of the generics industry.

MSF believes there is a crucial need to convince policy-makers to refocus policies towards more sustainable solutions. They need to be shown how some short-term interventions may not maximise public health goals.

In conclusion, there is a need to:

• Reduce reliance on donors and promote differential pricing
• Improve generic production for many drugs instead of resorting to single disease drug donations
• Encourage governments, NGOs and intergovernmental bodies to support policy frameworks that promote long-term solutions
• Increase research on: (i) the impact that donation programmes have on access (ii) the distortions caused by donations (iii) the impact of US tax code incentives on public health and the development of the generic industry in other countries (iv) the future of the generics industry in the context of intellectual property agreements (TRIPs).

Discussion

A question of equity
Participants emphasised the inequity that such public-private ventures can create. If a business enters a partnership with a government, only its employees will benefit, said one member of the audience. While corporate social responsibility is desired, equity is lost. Why should public money help support one company's employees?

The link with trade
Some considered it no coincidence that Boehringer Ingelheim had made a five-year contract for the GTZ initiative mentioned during the morning's programme. By the year 2006, least developed countries need to implement trade legislation related to intellectual property rights (TRIPs). The cost of the drug discussed, nevirapine, was estimated to be about US$4 per pill, but the generic version was thought to be much cheaper.

Another said the real cost for Boehringer Ingelheim was certainly not US$4 a pill. Once the factory is set up and selling medicines in Western countries the marginal extra cost is relatively low, he suggested. He estimated that the company's cost is probably one-tenth or one-fifth of US$4. Considering that price, he said, the company is receiving a great deal of prestige and has a lot of power in controlling the programme.

Drug donations
A number of participants spoke on the fact that drug donations are often used by drug companies to stop or slow the introduction of generic products and other mechanisms aimed at improving access such as compulsory licensing and parallel importing. They said companies have many reasons to make donations. These include corporate philanthropy, public relations by enhanced public image and influence, increasing revenue and tax reductions. Donations may block generics.

Another participant emphasised that the real costs of donations must be considered. There is a distortion of costs to public health programmes. In South Africa, for example, so much time has been spent on setting up systems for assessment. (This was a condition made by a company before a partnership programme could start.) That is an immense cost. Participants suggested that governments need to make a policy about what they will accept. If a country accepts all donations, it no longer controls the policy on essential drugs and vaccines.

The speaker from Médecins Sans Frontières was asked if the NGO had ever been approached by pharmaceutical companies about possible partnerships. He was asked if MSF had a policy on this. The speaker replied that MSF has knocked on industry's door in the past. While the organisation has accepted donations, about two years ago it began to question if this was the right choice. MSF is now aiming to improve access in other ways including the purchase of generics. He was then asked if speed is of the essence and if donations could be faster than other options, might MSF then ignore the long-term problem of continuously accepting donations. Guilloux said he saw the point but in MSF's view, long-term is about six months. He stated that MSF would not lose sight of its goal to explore other options since it does not consider donations sustainable.

Partnerships as a marketing and public relations tool
While many highlighted the fact that companies use partnerships as a marketing and public relations device, the audience was reminded that governments and international organisations use them for image-building purposes too.

Improving health systems
A comment was made that GTZ had written a paper listing the conditions necessary before it would become involved in projects on mother-to-child HIV transmission. They had reviewed the benefits and risks and had drawn up a comprehensive list of criteria. GTZ had concluded that the right circumstances need to exist before a joint venture can be considered. Conditions cannot be met today in many parts of sub-Saharan Africa. Health services are disintegrating. Many in the audience agreed that partnerships should be more closely linked to health services. Public-private partnerships tend to divert the attention of governments and transform country health agendas. These partnerships give money to specific disease-oriented programmes. Officials are told they will get something for free, but actually it may still involve huge, additional costs. There is a need to shift the focus back to the health care system. Industry often argues that failing infrastructure is the reason that access to needed drugs is limited in many countries. However, the point was made that drug prices and trade legislation, including TRIPs, are also key issues. Public health advocates have to ensure that industry does not use that smokescreen when discussing ways to improve access.

The question was raised: couldn't UN agencies and governments devise criteria for involvement the way that companies do? Governments need to prioritise. One has to discuss how health systems could really be improved. How health workers could obtain higher salaries was suggested as a good place to start. Perhaps governments should stop all partnerships and negotiate with the private sector to obtain funding to improve health systems. There is a need to think differently and much more imaginatively. We shouldn't think just in terms of vertical programmes that fragment the public health system.

Others emphasised the need for accessible, affordable drugs now. Improving health service delivery will take time. What is supposed to happen until that change occurs?

A number of speakers suggested that the focus be placed on structures of health services delivery. The lack of access to HIV/AIDS medicines provides a good example. People living with HIV/AIDS have strongly proposed ways of increasing access. They demand help. At the same time, we know that prevention efforts are crucial. The challenge is to find ways to strengthen preventive measures and assist those who are living with the disease. We need to go beyond advanced antiretroviral (ARV) therapies and back to basic health services to help those who are severely ill. We should also remember to provide the basic drugs for opportunistic infections that accompany AIDS. to fight diseases with basic drugs. ARV therapies are very much in vogue, but unaffordable for the poor. Unfortunately, a pill will not end this crisis.

Another participant suggested that the debate needed to move away from AIDS as a main reason for the distortion of health systems. She noted that structural adjustment programmes have also caused health systems to disintegrate. They spread neoliberal policy and its focus on privatisation and deregulation. That is also in the interest of global industry, she said.

The impact on the UN and WHO
Of concern is also how public-private partnerships may affect the possibilities for open, critical debates on public issues. At the March 2000 WHO-UNICEF Technical Consultation on Infant and Young Child Feeding, three out of nine backgroun papers were censored by WHO, a participant pointed out. Critical points about the infant food industry were removed. In addition, WHO attempted to prevent the technical experts from discussing the appropriate duration of exclusive breastfeeding. At that time, WHO and UNICEF recommended that infants should be exclusively breastfed for the first four to six months of age. The experts at the meeting supported a change of policy from four to six months to six months. The industry has always supported the four to six months recommendation. It provided them with two extra months to promote and sell their complementry foods, she said.

Political will is weakened by industry, said a participant. We need to better regulate industry. The World Bank now propagates a new development model in which they allegedly want countries to decide independently about their development. In fact, she stated, the World Bank proposes a tripartite decision-making process in which governments, civil society and business are called to discuss priorities and come to consensus. She voiced the opinion that we need to change these discourses. We may need to say no to business involvement in democratic decision-making as well as some of their donations. We must stress that they are not partnerships, they are donations. We also need publicly discussed guidelines to see if the donations suit public priorities.

The UN has indeed been weakened by decreased funding by member states. The WHO has shifted towards a model of public-private ventures. There is a crucial need for WHO to be strengthened so it can reclaim its role in global policy-making. Everyone seems to think that private sector funding is the only source available for health campaigns. One participant suggested that certain items could be taxed to help achieve public health goals.

Some issued a call to get back to basics. We need to determine how the fragmentation started. Who is undermining the UN and why? Currently, there is no co-ordination between public-private initiatives. People don't want their tax money to go into such fragmentation. Research suggests more money is spent on co-ordination than on real needs. Governments are busy doing public relations just like companies. The governments are also panicking; they see people dying and need drugs to treat them. Public-private ventures get the drugs, but there is no public health service, so public-private partnerships are called in to repair health services. There is a need to identify basic problems and look at possible solutions. Industry is not the solution, some said.

Another member of the audience stressed that it is easy to talk about the UN as an independent bureaucracy. However, in fact, it works with representatives of governments and responds to pressures put on it by them. Every international organisation or UN body fears cuts in US contributions. Membership contributions are important but how the agency uses the money is also crucial. The management is co-responsible for fragmentation, she suggested. Health systems are on the WHO agenda but they are not a 'sexy' item. They are often not a top priority for governments. We need to recognise that the statement 'polio has been eradicated' is a celebrated fact but 'repairing health systems' sounds less appealing to the public. We need to build a solid base of citizens' groups that will demand discussion on ways to improve health systems. Although it will be a slow process of change, it is our responsibility to demand that debate.

The role of governments
One audience member pointed out a clear distinction between the Daimler project and the Boehringer Ingelheim initiative mentioned in the German Ministry (GTZ) presentation. One involved a preventive strategy on AIDS, an established public health approach in the work place, and a good social context. The GTZ drug company case differed from that model: here, the company approached GTZ. There is a lot of secrecy involved in these kinds of deals, he said. Limited information is available. Money, skills and infrastructure are all involved. The question is: where should government agencies such as GTZ put their money and energy? Intra-sectoral approaches need money and research requires money. That is where funding should go. It is important to consider the impact of interventions.

Individual versus collective ethics
Partnerships gain support because they are said to help individuals, noted an audience member. But it's not fair to discuss them during emergency situations. Their long-term health gains need to be separated from the pressure caused by the understandable, human reaction to 'do something'. There is a need to discuss collective ethics, not just individual ethics. We need to see the accessibility of drugs as a human right and drug availability as the task. Why can't companies be taxed to raise the needed funding? That option should be part of a public discussion.

Direct and indirect impacts
Many felt it was good to see attention focused on the responsibilities of corporations, especially regarding accountability and so-called philanthropic projects. There is a growing voice looking at accountability in order to protect and promote the human right to best possible health as set out in human rights declarations. We need to examine companies' direct impact on health through pricing and research budgets. There is also a need to analyse indirect consequences. We need to build public health capacity. We need to measure the impact of interventions. How do companies impact public health? It is not only through drug donations. We need to look at things at a more fundamental level.

Collecting evidence about partnerships
The MSF presentation emphasised the need to scrutinise critically all 'gifts'. The idea that donations cost taxpayers four times more than any other model calls for further assessment, many thought. Another added that the MSF report will be helpful by providing a clear framework. The costs to recipient countries should be added for such things as taxes and agent fees. One said NGOs need to examine which model provides the most benefits: receiving expensive brands or buying low cost generics.

Many agreed that there was a crucial need to evaluate the effects of public-private ventures. Some doubted if donors would be very interested to pay for this kind of research. Others suggested that a great deal of information is already there, but not so accessible. NGOs have to push for greater information access and disclosure.

Some NGO research and awareness-raising is already taking place. For example, the UK-based NGO Baby Milk Action and five other organisations working with the International Baby Food Action Network (IBFAN) have received a grant from the EU Commission (DG Development) to gather information about the impact of factors related to the global economy upon infant health.

This seminar has tackled these issues very broadly, said one participant, especially the changes in terminology. But some key aspects still need to be addressed. This includes the effect that public-private ventures have on research. The public is often unaware that research is sponsored or co-sponsored by the companies. Also, we need more information about how trials and ethics have been addressed in public-private interactions. It isn't enough to be transparent. We need science carried out in the public interest.

More research and development in the vaccination field is needed. There are push-pull alternatives in the AIDS vaccination field. We need to use public resources as a push-pull mechanism to guarantee a market for the industry. Pull has lots of appeal; industry will pay for distribution to developing countries and will ensure a market. The problem lies in promoting development. It is better to encourage public institutions to develop vaccines and get generic industries to produce them.

Addressing real needs
One participant said in India they have seen the promotion of the hepatitis B vaccine. He wondered why the WHO advocates the hepatitis B vaccination? In the past, other vaccines have received strong support and then over time that support has faded. How can we be sure that the hepatitis B vaccine is really what is needed? Countries are not asking enough critical questions. They need to ask: What will the public benefit be? WHO and global alliances are promoting the need for new vaccines. Countries should question if this is a priority for them.

Industry's motivation
Medicalising all health problems has become popular, said a member of the audience. Non-drug solutions are rarely put forward as a solution. NGOs involved in partnerships want a quick return. Everyone is looking for fast returns on grants. While it is tempting to take the money for short-term results, it can be damaging to health in the longer-term.

This seminar has helped show how all of these aspects are connected, remarked some participants. The fact that big vaccine initiatives started in 2000 has to be considered. There are obvious links to litigation involving companies taking part in alliances and the coming trade regulations. Industry gains important advantages through partnerships including: direct access to policy makers; means to improve a company's image; genetically engineered vaccines that are high-tech and undermine more traditional vaccines; and faster drug approvals.

The risks involved are not slight. They can reduce the political advocacy role formerly held by UN agencies. To avoid being instrumentalised by corporations it is also important to correctly characterise such joint ventures. Some thought the term 'corporate philanthropy' should not be used, instead, it should be called 'corporate sponsorship'. The importance of strategic public relations should not be underestimated. One must realise where the money from the partnership comes from and expose the strings that are attached.

Public-private partnerships are win-win-win situations for companies, emphasised one member of the audience. They are inexpensive, they find favour and there is no democratic control. He said he has attended meetings at WHO with donor countries and developing countries. There have been big changes in how industry is viewed in such fora. First, all those invited met as interested parties involved in a WHO programme. This included business-interest NGOs (BINGOs) and public-interest NGOs (PINGOs). Now these meetings are attended by industry partners. Even the spatial arrangements at the meetings have changed. Industry has a seat at the main table and the few NGOs present are seated in the back of the room. For some reason, there are no specific terms of reference for industry participants any more. Now all parties are considered part of the 'Essential Drugs Family'.

The role for NGOs
One participant suggested that corporate public relations and sponsorships will remain. The question is: do we want to push it in a certain direction? That is, into technology transfer or towards needed research and development? There needs to be a stronger public voice on what it should be. There is a need to be more strategic. The current situation does not have to be accepted as the way things have to be.

There are different types of interactions with industry that may call for different responses, said an audience member. On some things one should just say no. On others, we should look at ways to go forward. There are differences between product pushing and more general funds. There is a difference between projects meant primarily to polish corporate image and those set up to change global health policy. In all, the need for transparency is paramount. There must be a clear differentiation between public health goals and product promotion. There needs to be a classification structure that helps differentiate between all of varied types of public-private interactions taking place.

The current situation does not have to be accepted as the way things have to be.

We should look at ways to go forward. There are differences between product pushing and more general funds. There is a difference between projects meant primarily to polish corporate image and those set up to change global health policy. In all, the need for transparency is paramount.

Conclusion by the chair

Charles Medawar, Social Audit, UK

Today's seminar tackled a hugely complex issue. The atmosphere has been extraordinarily good. In today's world, it feels like public-private partnership is a new drug that we need. But innovation can be good, bad or indifferent and the same tends to be true of the public-private mix. Idealisation is risky and there is huge uncertainty regarding the costs and risks of public-private ventures.

Newly developed drugs are being heavily promoted even though we often don't know their long-term effects. Critics trying to speak out about their risks are marginalised. When a new drug is introduced we can see benefits and risks in small amounts. Some drugs do good, many do little, some are total disasters. The same is true for public-private partnerships.

The discussion has given some ideas on essential issues to be addressed:

• The need for accountability
• Greater transparency and increased access to information
• Development of criteria to define what is a truly beneficial public-private interaction
• Distinguishing between various types of public-private relationships and acknowledging the differences.

This issue should be a priority and we all need