Pitfalls in International Partnerships

In an increasingly globalized world, the boundaries that separate traditionally national issues are being blurred. In this global climate, we can no longer talk about “international health,” which emphasizes the interactions of discrete localities; rather, we must approach global health issues with a focus on the dynamic and interrelated forces that transcend national boundaries. Central to this process is the collaboration of different sectors and diverse players to address the broad and complex determinants of health. Recently, an emphasis has been placed on Global Public-Private Partnerships (GPPPs) to holistically improve global health disparities.

There are varied definitions of partnership, such as a “collaborative relationship between entities to work toward shared objectives through a mutually agreed division of labor.”(1) This type of partnership may also include “a mechanism to assess success and make adjustments” or “an agreement to work together to fulfill an obligation or undertake a specific task by committing resources and sharing the risks as well as the benefits.”(2)

Other conceptions emphasize shared goals: “A health GPPP as a collaborative relationship which transcends national boundaries and brings together two or more parties, among them a corporation (and/or industry association) and an intergovernmental organization, so as to achieve a shared health-creating goal on the basis of a mutually agreed division of labor.”(3)

In all of these definitions is the idea that corporate, nonprofit, and public sectors can learn from each other. By bringing together diverse players, GPPPs benefit from the strengths of each: the mission of a non-profit, the scale of government, and the efficiency of industry. As the actions of one sector affect the ability of the other to achieve its goals, partnerships can result in win-win interactions between private and public actors.

In fact, when it comes to health policy, there seems to be a consensus that the government does some things best, the private sector does other things, and the not-for-profit sector still different things. In theory, public-private international partnerships could combine the best of each, but in practice they do not always do so. What happens when a foreign NGO partners with a local government and one partner do not follow through or fails to effectively communicate? Outlined in this article are several pitfalls that can occur in global public-private partnerships.

Pitfall 1: Unequal Responsibility

One issue that may arise in multi-sector partnerships is an unequal distribution of responsibility. Such a power differential may be the result of one partner having more resources or local influence than another and can lead to domination by one entity. For example, when responsibility is not shared between the public and private sector, NGOs can undermine the local public health infrastructure and weaken the health care system. The case study presented here illustrates how the NGO model can fragment the public health sector.

Pitfall Case Study: NGOs in Mozambique

After destruction of the public health system from a war initiated by the Mozambique National Resistance, the government began an International Monetary Fund-promoted structural adjustment program in which government services were cut back, prices increased, and a free market economy promoted. By 1990, state per capita spending on health was half of its 1980 level.(4) These neo-liberal structural adjustment policies created a void in the public health sector. In keeping with an emphasis on privatization, international aid was channeled through non-governmental organizations to fill in this gap and support primary health care in the Global South.

“As national health system salaries plummeted, health workers became vulnerable to financial favors offered by NGOs seeking to promote their projects in turf struggles with other agencies.”(5)

By the late 1990s, the NHS received about 50% of recurrent expenditures and 90% of capital expenditures from international donors.(6) Even though many projects were integrated into NHS programs, Mozambicans often did not have genuine control over budgets or project development.(7) There were frequent reports that pharmaceuticals were being stolen from the health service and sold to market vendors or administered on a fee-for-service basis at the private homes of health service workers. For example, one survey found that over half the health posts in one district had no chloroquine tablets for malaria treatment even though abundant supplies had been delivered to the province.(8) Health workers reported that the chloroquine had been diverted to private practice or sold to private vendors in the open markets.

“The inundation of the health sector by international NGOs since the late 1980s damaged the PHC system and contributed to intensifying social inequality in local communities with important consequences for primary health care delivery. If the millions of aid dollars had been provided directly to the NHS to increase salaries, improve health worker conditions, strengthen systems of accountability, and more rationally allocate resources there would have been even better coverage, service quality and health outcomes."(9)

Pitfall 2: Conflict of Interest

A central question that confronts GPPPs is whether it is possible to ensure that core public and private values are preserved in partnerships which promise win-win situations. Differences in values may occur because there is an inherent conflict of interest when private sector actors are involved in a partnership.(10) One critique of public–private partnerships is that the private sector has several mechanisms for maximizing profits which may conflict with other goals.(11)

“Stockholders’ interests must come first when the private partner is a for-profit organization. This makes for divided loyalty, and it conflicts with public policy obligations to society.”(12)

However, Lenton Berkley of the International AIDS Vaccine Initiative (IAVI) has argued that shared goals are more important than shared values.(13) This is because shared goals can transcend conflicting values. Without agreement on shared goals, GPPPs can suffer from the pitfall of conflicting interests, as illustrated by the case study of pharmaceutical marketing in the Global South.

Pitfall Case Study: Pharmaceutical Marketing in the Global South

The history of the pharmaceutical industry’s marketing of its products in the Global South demonstrates the need to proceed with caution and to examine each proposed partnership according to appropriate guidelines and criteria.(14) For example, the suitability of the pharmaceutical industry as a partner for World Health Organization has been questioned due to a perceived conflict of interests.(15)(16)

The promotion of social justice through GPPPs may not be easy.(17) This is because resource allocation through partnerships may not be according to burden of disease calculations or need, but according to how a particular partnership reflects the views of its members. The donation of Zithromax® provides an example. Although the drug is effective against sexually transmitted infections, it was not until the discovery that Zithromax® could be used to treat trachoma that it was donated for use in some low- and middle-income countries. It has been suggested that this is because public corporate involvement in the control of stigma-laden sexually transmitted infections would have caused discomfort to the shareholders, while preventing blindness had a more positive appeal.(18)

In addition, pharmaceutical industry partnerships are selective in terms of the countries in which they choose to operate. For example, while Merck’s Mectizan® Donation Programme operates in all countries where onchocerciasis is endemic and has agreed to donate the drug until these diseases are eradicated, the International Trachoma Initiative (ITI) has decided to donate Zithromax® to only five of the 16 WHO priority countries which have significant populations with trachoma and has committed itself to only two years’ donation.(19)(20) Thus, the ITI has chosen to work in countries which are perceived to be ‘less difficult,’ causing large populations to be excluded from this program. Without a clear standard of conduct and agreed upon goals, the efficacy and appropriateness of GPPPs will be undermined.

Pitfall 3: Lack of Transparency and Accountability

Both the public and private sectors have well-established mechanisms of accountability, or ways to assure that partners are held responsible for their actions.

“In the private sector, management is accountable to the company’s shareholders. In the public sector, administrative structures report to political structures that are ultimately accountable to the ruled through the contestability of political power.”(21)

However, accountability within public–private partnerships may be less straightforward, partly because of the distance between the global partners and the beneficiaries. “In transnational NGO networks, ‘downward accountability’ is often weak, and is particularly limited when geographical distances are great or international as well as local organizations are involved in a project.”(22) Given that accountability is dependent upon the clear specification of objectives, activities, roles, and responsibilities, it will be more easily achieved in formal partnerships where these are spelled out and activities are transparent. In contrast, partnerships whose goals and division of labor are vaguely defined will lack accountability. A study of the Peruvian National TB Program illustrates best practices in accountability and transparency.

Positive Case Study: Peruvian National TB Program

As Director of the Peruvian National TB Program, Pedro Suarez saved a failing public health initiative by increasing accountability and transparency in multi-sector partnerships. Peru, suffering from substantial debt due to structural adjustment policies, a civil war, and rapid urbanization, had high rates of multi-drug-resistant tuberculosis. As little money was funneling into the public sector, Suarez took the stories of the Association of Patients with TB, an advocacy group, to government officials. “TB is not only a public health problem, it’s a social and political problem,” he told them. By framing tuberculosis as a social issue with political implications, Suarez was able to partner with multiple stakeholders and secure funding from Peru’s Fund for Social Development aimed at fighting poverty.

One way in which Suarez achieved accountability was by assembling a diverse team and emphasizing the interconnectedness of all the players. Suarez used contacts at professional membership associations – the Association of Social Workers, the Association of Nurses, and the Medical Association – to advertise positions with the NTP. Three candidates—a social worker, a nurse, and a physician—were hired to become Assistant Directors of the National TB Control Program. In addition, many local-level health workers were hired on a contract basis. By employing individuals at the local and policy level in different sectors of health, Suarez established a system of accountability in which each representative was accountable to his or her own constituency and to one another.

In order to support this accountability network, Suarez created a transparent environment. In November 1990, Suarez invited all the health officials working for the NTP at the departmental and intermediate level to a two-day meeting in Lima. He explained:

“It was our first contact with the people who worked at the intermediate level. We asked everyone to just come and share their information. We wanted to see the epidemiological and operational information. We knew we wouldn’t be able to reach everyone or get one agreement, but we just wanted to hear about what people wanted and where they were.”(23)

The Future Promise of GPPPs

In summary, while there is much potential for the success of GPPPs, there remain many uncertainties and some cause for concern. Research is needed to learn more about what makes a partnership 'effective' and what best practices exist. Only by ensuring transparency, accountability, and equal representation and by avoiding conflicts of interest in partnerships can GPPPs effectively address the complex issues in global health.

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(1) Kamel, Nawal, et. al. Partnership for development: proposed actions for the World Bank - a discussion paper (English). Washington, DC: World Bank, 1998. http://documents.worldbank.org/curated/en/789141468153858137/Partnership-for-development-proposed-actions-for-the-World-Bank-a-discussion-paper.   

(2)“Partnerships with Business.”Department for International Development, 1999, http://hedon.info/docs/bpu-partners.pdf.

(3) Buse, K, and G Walt. “Global Public-Private Partnerships: Part I--A New Development in Health?”Bulletin of the World Health Organization, World Health Organization, 2000, www.ncbi.nlm.nih.gov/pmc/articles/PMC2560730/.

(4) Cliff, J. (1993). Donor-dependence or donor control?: The case of Mozambique. Community Development Journal28(3), 237-244.

(5) Pfeiffer, J. (2003). International NGOs and primary health care in Mozambique: the need for a new model of collaboration. Social science & medicine56(4), 725-738.

(6) Walt, G., Pavignani, E., Gilson, L., & Buse, K. (1999). Health sector development: from aid coordination to resource management. Health policy and planning14(3), 207-218.

(7) Hanlon, J. (1991). Mozambique: Who calls the shots?. London: James Currey.

(8) Pfeiffer, J. (2003). International NGOs and primary health care in Mozambique: the need for a new model of collaboration. Social science & medicine56(4), 725-738.

(9) Ibid.

(10) Kanter, R. M. (2000). Business coalitions as a force for regionalism. In B. Katz (Ed.), Reflections on regionalism. Washington, DC: Brookings Institution Press.

(11) Hancock T. (1998). Caveat partner: reflections on partnership with the private sector. Health Promotion International, 13 (3): 193.

(12) Rosenau, P. V. (2000). The strengths and weaknesses of public-private policy partnerships. In P. V. Rosenau (Ed.), Public-private policy partnerships. Cambridge, MA: The MIT Press.

(13) Berkley S, Lenton C. The International AIDS Vaccine Initiative. Paper presented at the Third Global Forum for Health Research, 8–11 June 1999, Geneva.  

(14) Chetley A. A healthy business? World health and the pharmaceutical industry. London, Zed Books, 1990.

(15) Hancock T. (1998). Caveat partner: reflections on partnership with the private sector. Health Promotion International, 13 (3): 193.

(16) Buse K, Walt G. (2000). Global public–private health partnerships: Part II — what are the issues for global governance? Bulletin of the World Health Organization, 78: 699–709. www.ncbi.nlm.nih.gov/pubmed/10859865.

(17) Foege WH. (1998). Ten years of Mectizan. Annals of Tropical Medicine and Parasitology, 92 (1): 7–10.

(18) Buse K, Walt G. (2000). Global public–private health partnerships: Part II — what are the issues for global governance? Bulletin of the World Health Organization, 78: 699–709. www.ncbi.nlm.nih.gov/pubmed/10859865.

(19) Cook J. Personal correspondence with J Cook, Executive Director, International Trachoma Initiative, 20 May 1999. www.trachoma.org/about-trachoma.

(20) Mabey D. Personal communication, Member of Technical Expert Committee, International Trachoma Initiative, London, 28 June 1999. www.trachoma.org/about-trachoma.

(21) Ibid.

(22) Bain K. (1999). Building or burning bridges? The accountability of transnational NGO networks in policy alliances with the World Bank. Paper prepared for the Conference on NGOs in a Global Future, Birmingham.

(23) The Peruvian National Tuberculosis Control Program. Julie Rosenberg, Joseph Rhatigan, and Jim Yong Kim prepared this case for the purposes of classroom discussion rather than to illustrate either effective or ineffective health care management practice. The Brigham and Women’s Hospital helped provide financial support for the production of this case. Copyright 2008 by the President and Fellows of Harvard College.