Proceedings of a Workshop

Public–Private Partnerships for Global Health at the National, Municipal, and Community Levels

Proceedings of a Workshop—in Brief

The National Academies of Sciences, Engineering, and Medicine’s Forum on Public–Private Partnerships for Global Health and Safety¹ convened a workshop on October 23–24, 2019,² to examine the enabling environments for public–private partnerships (PPPs) in global health at the national, municipal, and community levels. Panelists presented case studies on the mechanics of building a partnership in a specific region, described the conditions that the private sector needs to establish itself in that region, and discussed how a country’s public-sector leaders prepare to accept private-sector partners in collaborative efforts that provide health care products and services intended to support and advance the public good.

DEFINING THE ENABLING ENVIRONMENT

Keynote speaker Emmanuel Nyirinkindi, director of transaction advisory services at the International Finance Corporation of the World Bank Group, noted that approximately 400 million people across the world lack access to basic health services, and millions of others live in poverty owing to unmanageable health care costs. In 2012, the United Nations (UN) General Assembly asked governments to increase their efforts toward universal health care. Nyirinkindi explained that PPPs have the potential to achieve this goal by merging the access and quality found in the private sector with the equity and affordability found in the public sector. He presented seven essential conditions for a PPP: (1) an arrangement between public- and private-sector entities, (2) provision of services by a private partner for public health benefit, (3) private partner investment in and/or management of public assets, (4) defined time period of the contractual arrangement, (5) risk sharing between contracting parties, (6) standards that emphasize quality of service and performance, and (7) payment linked to performance.

Nyirinkindi said that health-sector PPPs generally fall into one of the following categories: health infrastructure PPPs, clinical services PPPs, or health continuum PPPs. A health infrastructure PPP is established through a privately financed initiative (PFI) (e.g., a ministry of health has an agreement with a private-sector partner). The private-sector partner constructs and maintains the infrastructure to deliver services to the public-sector partner, who in turn pays the private-sector partner. Patients receive clinical services via the public-sector partner. The benefits of a PFI may include quicker construction and equipment procurement, better equipment maintenance, and transferred risk of cost and time overruns to the private sector. Challenges for developing countries could arise if the public entity has difficulty securing financing, providing clinical services (owing to a lack of staff), or managing demand. Nyirinkindi shared

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several examples of successful PFIs, including a PPP in Egypt supported by an international consortium and a 20-year concession, which led to a 424-bed project with 2 hospitals and 1 blood bank facility. This project required an investment of $225 million and improved access to health care for 78,000 people.

Nyirinkindi explained that in a clinical services PPP, the private sector takes on the additional responsibility of providing clinical services and receives payment from one or more of the following: the public-sector partner, directly from patients, and from health insurance. According to Nyirinkindi, the benefits of this model are that nearly all risks are transferred to the private partner, the cost to the government is reduced, and contract management is easier. It allows the private sector to bring efficiencies and innovation into construction and to better train staff. Challenges with this model are similar to those of health infrastructure PPPs. He provided several examples of successful clinical services PPPs, including a PPP in Bangladesh with a 10-year contract and $2 million in private investments to refurbish, equip, operate, and manage dialysis centers at two government hospitals. This PPP improved access for 100,000 people and drastically reduced out-of-pocket expenses.

Health continuum PPPs are less common. These entities provide care for ill patients and focus on preventative services, but, according to Nyirinkindi, this model works only in countries that have a health system in which all hospitals participate and in which every citizen can be identified. Spain’s Alzira Hospital PPP is an example of a successful health continuum PPP, with a 91 percent patient satisfaction rate.

Nyirinkindi commented that if constructed, managed, and regulated properly, PPPs provide the accountability that is currently lacking in many public hospitals. He emphasized that the following 10 conditions can create an enabling environment for a successful PPP: (1) strong political commitment, (2) alignment with a broader health strategy, (3) appropriate risk sharing, (4) public-sector capacity that includes monitoring, (5) early evaluation of the fiscal space, (6) legislation and regulation, (7) private-sector capacity, (8) a focus on service delivery, (9) transparent tender (project bidding) and decision-making processes, and (10) proactive stakeholder engagement.

HOW HEALTH-FOCUSED COMPANIES TAKE ROOT IN COUNTRIES AND MUNICIPALITIES: THE EXPERIENCES OF THE PRIVATE SECTOR, MINISTRIES OF HEALTH/PPP UNITS, INTERMEDIARIES, AND LOCAL-LEVEL DISTRIBUTORS

Panel 1: Medtronic’s Experience Establishing a PPP in East Africa

Trevor Gunn, vice president of international relations for Medtronic, noted that many medical technology companies enter into PPPs to provide diagnostic solutions. However, Medtronic specializes in implantable and disposable technologies for disease management. Although PPPs can be risky for for-profit companies, he explained that, from Medtronic’s point of view, they offer great opportunity: PPPs align with Medtronic’s mission to increase patient access to medical devices; offer an avenue into the public sector, specifically into public-driven health care systems; and allow Medtronic to diversify and increase revenue. Medtronic offers four types of solutions via its engagement with government entities in PPPs: (1) research and development, which can increase economic value for a country; (2) manufacturing for market access; (3) clinical training and education on Medtronic therapies; and (4) health system strengthening to reach more patients and improve both the delivery and quality of care. Gunn said that Medtronic assesses countries for PPP readiness through many variables (e.g., government effectiveness, ease of doing business, enforcement of contracts, protection of investors, creditworthiness, legal framework, public health burden, health care agenda, and regulatory environment). He asserted that Medtronic continues to improve its internal readiness for partnerships and is attracted to Kenya’s focus on universal health care.

Anne Ng’ang’a, head of the Division of Health Care Equipment at the Republic of Kenya Ministry of Health, commented that the Ministry of Health is guided by a national health system strengthening approach. The Constitution of Kenya, 2010, guarantees citizens the right to health care and delineates roles for both the national and county governments in providing health care services, and the Kenya Health Policy, 2014–2030, aims to raise the country’s standard of health as it works toward implementing universal health care. The Kenya Health Policy could enable increased collaboration with the private sector through the development of a health policy framework focused on PPPs; the establishment of appropriate legislative frameworks and guidelines to facilitate private-sector engagement (while working within the existing laws and regulations); and developing incentive mechanisms that attract private-sector actors who could work with the public sector. She said that Kenya’s Public Private Partnerships Act, 2013, establishes the legal basis for PPPs. They are selected through the review of internally generated feasibility studies, which are approved by Kenya’s National Treasury PPP Committee.

These studies indicate the technical and legal requirements; social, economic, and environmental impacts; efforts related to universal health care; affordability; value for money; and comparison to a public-sector project. National

and international bidders then prequalify after the Ministry of Health has posted advertisements. The National Treasury PPP Committee selects projects based on compliance with the PPP Act and alignment with national priorities. The PPP Unit, which serves as the secretariat and technical arm of the committee, provides technical, financial, and legal expertise; raises awareness; and conducts capacity building to various government agencies. It also serves as a secretariat for the national and county governments’ PPP project inventory, acts as a screening body for requests for information and government support, identifies and supports performance improvement efforts, conducts risk analysis, monitors contingent liabilities and accounting issues, and ensures that the guidelines of the PPPs are implemented properly. Ng’ang’a noted that county governments can engage with PPPs as long as they remain within the guidelines of the PPP framework. She emphasized the need for Kenya to have the appropriate capacity to negotiate for and enforce contracts, continue competitive bidding, and ensure adequate risk transfer.

Francis Muraya, senior economic advisor to the president of Kenya, explained that Kenya comprises 47 counties with 47 governors, which complicates capacity building and resource allocation. PPPs could increase the efficiency of health service delivery as well as expand business opportunities for the private sector, he continued. He noted that Kenya’s current PPP agenda has an estimated cost of $10 billion and a pipeline of 73 projects; however, none are related to health care. The projects are primarily in the energy sector, which has expertise and capacity. PPPs in health care have not yet been successful owing to a lack of ownership among contracting authorities, unbankable projects, tender wars among bidders, conflicting interests and expectations, complicated approval processes, and procurement delays. President Kenyatta has asked Muraya to restructure the PPP Act in the hope of achieving his goal to build five cancer hospitals within the next 3 years.

Echoing Nyirinkindi, Muraya said that for PPPs to be successful, political goodwill is needed at the highest level. He proposed that President Kenyatta chair a PPP steering committee, which could increase buy-in from the cabinet secretaries, bring trust to the PPP agenda, and help financial deals to close. He also proposed that the current process to approve a PPP project be substantially simplified. Funds could then be allocated for viability gap funding, which is important because some nodes are unfunded, incentives could motivate line ministries to become involved with the PPP agenda, and the PPP pipeline could be publicized in a way that would attract bidders. Muraya expressed hope that other countries will eventually view Kenya as a place with affordable health care, high-quality facilities, and highly trained medical staff.

Ruben Vellenga, Sustainable Development Goal (SDG)³ Partnership specialist and lead for health at the UN Office of the Resident Coordinator in Kenya SDG Partnership Platform, explained that his organization serves as a neutral broker to build ecosystems in Kenya where partnerships can flourish. He reiterated the importance of bringing universal health care to Kenya, which presents challenges given the existing inequity issues. Because Kenya is noticing a decrease in donor and similar aid, new models that can sustainably expand the market and provide services are needed, he continued. Kenya’s national-level commitment creates opportunities for novel partnership. He noted that health care PPPs in Kenya could fast-track the delivery of universal health care and begin to stimulate long-term investments by private companies, creating value for money for the system. The government struggles with technology development, so the private sector also plays an important role in creating efficiencies through innovation in the public health system. He explained that the co-creation of PPPs allows for shared value models, which in turn lead to sustainable returns—private-sector partners deliver a larger effect through coordinated efforts, and investments are de-risked. He advocated for continued discussion about policy and regulation that could make PPPs more successful. If open dialogue continues, PPPs have the potential to address the needs of underserved populations, and trust could increase between the public and private sectors. He anticipated that successful collaborations in Kenya could serve as models for other countries.

Mary Matu, founder and executive director of Angelica Medical Supplies, which provides reliable and affordable supplies by working with companies such as Medtronic to serve customers such as the Republic of Kenya Ministry of Health, said that prior to the enactment of the PPP Act, the Kenya Renal Association set up a task force in 2011 to address the shortage of renal services in Kenya. The country had only five dialysis centers in the public sector, causing some patients to have to travel for days to get treatment. Working with Bellco,⁴ Angelica Medical Supplies was awarded a contract to equip and maintain Kenya’s hemodialysis units. In 2016, the Kenyan government began paying for dialysis services in the public sector, and 52 dialysis centers were offering services across the country by 2019. The number of nephrology nurses also increased from 60 to 600 through a partnership with the national referral hospitals.

Matu explained that collaboration enabled these successes: the Ministry of Health was the procuring entity, Bellco was the original equipment manufacturer, Germany’s DWA supported the water treatment plant, LUCKmed sup-

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ported other functional units, Angelica Medical Supplies provided equipment and training, and Roche Pharmaceuticals addressed health issues stemming from renal disease. Government bureaucracy was a challenge (i.e., the project was supported by the national government but was required to work with the county governments), as was building trust among international partners, she continued. Other challenges included financing, infrastructure, and human resource capacity. To address these challenges, Matu’s team negotiated with individual county hospitals, expanded partnerships and training facilities, received a letter of support from Kenya’s government, and consulted with stakeholders.

During a question-and-answer session with the panelists, Simon Bland, director of the New York liaison office for the Joint United Nations Programme on HIV/AIDS, asked about the importance of the bottom line in Medtronic’s decision-making process. Gunn described the need to provide clear messaging to investors about a potential change in margins when doing effective service-based work. Bland also wondered about ways to overcome political uncertainties when entering into partnerships. Muraya emphasized the value of strong institutions and noted that the United Nations has been bolstering the capacity of Kenya’s PPP Unit by providing technical assistance and resources. Scott Ratzan, executive director of Business Partners for Sustainable Development at the U.S. Council for International Business and senior scholar at the City University of New York Graduate School of Public Health and Health Policy, inquired about a facilitation framework to enable engagement from a municipal to a national to a global level. Muraya acknowledged the importance of best practices and explained that Kenya is adapting South Africa’s PPP model.

Panel moderator Katherine Taylor, director of global health training, Eck Institute for Global Health, University of Notre Dame, asked panelists to highlight the qualities of an effective partnership. Gunn recognized that the private sector has to earn the trust of the public sector, but he said that one way to improve PPPs is to focus on speed and efficiency at the county level to avoid the deal fatigue that frustrates private-sector partners. Ng’ang’a noted that this is the right time for the private sector to partner with Kenya, and she emphasized the need to understand how to engage effectively with county and national governments while working within legal frameworks to achieve health goals. Matu commented on the value of local partnerships, because that is the level at which cultural issues arise. Vellenga noted that effective partnerships emerge when missions align. He encouraged the private sector to come to Kenya with ambitious plans to address systemic issues. Kristie Mikus from the U.S. Centers for Disease Control and Prevention reflected on whether more private-sector entities might be interested in public health if the proposed partnerships were not formally defined as “PPPs.” Matu replied that a PPP is necessary if the issue relates to costly equipment because it allows the private sector to invest upfront and the government to recover its funds. Although not all problems are best approached with a PPP, Muraya said that PPPs make sense in Kenya, where 75 percent of the population cannot afford health care and need the government’s help.

Panel 2: Philips’s Experience Establishing a PPP in West Africa

Philips is a large, global health technology company headquartered in the Netherlands with a mission to enable better health outcomes, including for those populations without sufficient access to health care today. Will Center, head of international funding for Philips, described the company’s goal to reach 400 million people in underserved populations by 2030. Philips seeks collaborators with similar missions—in partnership with the United Nations Population Fund (UNFPA), Philips hopes to reach 50 million women and girls by 2025, primarily through the primary care system. A PPP among Philips, UNFPA, and the Republic of the Congo that focuses on improving emergency obstetric and newborn care is one step toward achieving this goal. Center said that the central objective of a PPP is to lower government costs and create greater impact for a community. If effective, PPPs could both enable universal health care and reduce risk for partners. Capital could be used more efficiently (rather than simply finding a return on investment) and digitalization could advance health care solutions. He commented on a broader initiative, the Philips’s Community Life Center Program, which has eight sites in Africa and expects to be affecting 1 million people by the end of 2020. Now the challenge becomes scaling these efforts. Center concluded by sharing three key steps to a transformational PPP: (1) have bilateral government-to-government memoranda of understanding (MOUs), (2) implement multi-year service agreements as contractual vehicles, and (3) streamline financing to reduce bottlenecks, perhaps via a primary health care fund.

Mariarosa Cutillo, head of the strategic partnerships branch of UNFPA, shared three potential outcomes of engaging in partnerships with the private sector: (1) addressing unfinished business, (2) leaving no one behind and making the invisible visible, and (3) reaching communities through platforms that focus on innovation and inclusivity. She explained that UNFPA entered into a partnership with Philips in the Congo not only because of its commitment to invest but also because of its proof of concept. She emphasized that partnerships will succeed with honest conversations and clearly defined roles and benefits. She added that this partnership has been endorsed at the highest level of leadership, so the UNFPA country office, together with Philips, has to be able to deliver results. The partnership has to be managed with consideration for key performance indicators (e.g., making a certain number of mothers in a remote

area who were previously invisible visible), beneficial for all stakeholders, and credible and accountable. Then, UNFPA has the potential to give visibility to a PPP that could have long-term impact.

Luc de Clerck, program manager and clinical lead for primary and community health care at Philips, explained that Philips has transitioned from selling technology to selling services as a solution. He described Philips’s partnership with UNFPA as a health care delivery training program, which is 80 percent services and 20 percent technology. He described an incubator that Philips created in 2014 for several sectors to work together, including the World Health Organization and the United Nations Children’s Fund. Through this initiative, an adaptive emergency obstetric and newborn care program could be implemented in more than 6 district hospitals and 60 primary health care facilities. This experience revealed the importance of PPPs, de Clerck asserted. Philips’s current partnership with UNFPA in the Congo is successful because it is built on trust and transparency. de Clerck explained that a national co-creation session took place in May 2018; next, technical partners from the country were involved in a co-creation session. This continued at the local, regional, and global levels until a solution was designed—three health districts selected by the Ministry of Health are being targeted over a period of 18 months. If this demonstration phase is successful, the next phase will include 30 health districts over 5 years. The goal is to implement a sustainable model for emergency obstetric and newborn care that health facilities can operate with minimal oversight. He emphasized that successful PPPs use digital solutions, think outside of the box, and communicate continuously, especially about risks, responsibilities, and benefits.

Mohamed Lemine Salem Ould Moujtaba, resident representative for UNFPA in the Congo, explained that UNFPA entered into the partnership once preliminary agreements had already been reached between Philips and the Congo. UNFPA contributes expertise at the national and local levels and ensures that international standards are applied within the Congo. Given that trust in the private sector is not always strong, he noted that UNFPA lends credibility and continuity to the partnership, having in place an established framework for working with the government of the Congo for more than 30 years. Center added that no money is exchanged between Philips and UNFPA, which preserves UNFPA’s reputation as an independent and unbiased partner. Moujtaba emphasized that partnership with the private sector is essential if a country’s agenda is to be accomplished, as is engagement with the government to invest domestic resources in a solution. He described the partnership with Philips and the Congo as particularly challenging owing to the number of stakeholders who are involved, making it difficult to reach consensus. He explained that the government in the Congo is not comprised of a single entity (e.g., even if the Ministry of Health approves, the Ministry of Finance has to be convinced to engage).

Thierry Katembwe, chief executive officer of the African Construction Company (ACC), is Philips’s local partner in the Congo. He explained that ACC had previously been involved with PPPs at the local level and is one of the few companies to have signed a PPP with the Congo’s Ministry of Infrastructure. This level of experience made ACC attractive to Philips—as the local partner, ACC ensures that Philips has social impact and does not lose money, as well as ensures that the state government, which was weary of the private sector, makes money for the state and improves the health of mothers and children. It remains a challenge to unite all of these interests and to obtain financing, but UNFPA has helped. He emphasized how important it is to listen to all of the partners—even though each has its own codes, politics, and languages, all have the same objective. He echoed Cutillo’s emphasis on leaving no one behind, especially underserved populations in remote regions—this PPP creates primary care facilities connected with hospitals to offer a new level of health care for mothers and children. Patrick Balou, secretary general of ACC, emphasized that international businesses can create local solutions that are in tune with people’s lives. He provided an update on the progress of the partnership: ACC is part of an MOU that has been signed, has a commitment from the Ministry of Finance, and has an agreement with Philips and the Ministry of Health that is awaiting approval from the Ministry of Finance.

Serving as panel moderator, Gunn asked about the content of MOUs. Center replied that MOUs provide a detailed framework to encourage the flow of private money into the global health space and allow officials to pursue conversations with the private sector. Katembwe noted that the MOU for the partnership in the Congo was based on the priorities of the Ministry of Health. de Clerck added that because MOUs are not legally binding, supplementary agreements are needed, and binding contracts eventually follow. Cutillo emphasized that if MOUs do not lead to an outcome, they have no purpose.

Andrew Wilson, director of corporate engagement at PATH, wondered about ACC’s experiences as the local private-sector partner. Balou said that after completing feasibility studies, it was possible for ACC to gain trust from the community and bring projects forward. However, Balou and Katembwe emphasized that many of ACC’s challenges were similar to those of the other partners, owing to the complexity of the ministries and the partnership’s high number of stakeholders. John Monahan, senior fellow at the McCourt School of Public Policy and senior advisor to the president of Georgetown University, asked if all signatory partners will receive the data they need to understand whether the partnership is working and to make adjustments for the future. de Clerck emphasized the need for regional and

local authorities to have the tools to take responsibility for the program. Thus, the PPP’s program management committee will provide data from the first phase of the project to a technical committee, which will be responsible for sharing relevant data with the Ministers of Health, Planning, and Finance.

Panel 3: Becton, Dickinson and Company’s Experience Establishing a PPP in India

Amy Piatek, senior tuberculosis (TB) technical advisor at the U.S. Agency for International Development (USAID), explained that while TB is the leading cause of death by infectious disease, it is the least resourced of the top infectious diseases: TB receives only 18 percent of The Global Fund to Fight AIDS, Tuberculosis and Malaria. TB is also one of the major causes of death attributable to antimicrobial resistance; as of 2018, only one in three people with multidrug resistant TB (MDR-TB) accessed treatment, and the number of people with MDR-TB who have been treated successfully remains less than 60 percent. She added that the only way to treat someone with MDR-TB reliably is to know the exact drug resistance profile, which is a tedious process. Although India has 25 percent of the MDR-TB cases worldwide, only two-thirds of patients have drug resistance profiles. She said that the infrastructure in countries that need access to testing is often weak, and treatment regimens are complex. USAID’s partnership with Becton, Dickinson and Company (BD) and India—Strengthen TB Resistance Testing and Diagnostic Systems (STRIDES)—is working to address this global crisis. Another effort, USAID’s Global Accelerator to End TB, could prompt investments in multiple countries and sectors to detect and treat 40 million cases by 2022. Piatek explained that USAID’s Bureau for Global Health has a long history of working with the private sector; it now has a private-sector engagement policy, which could demonstrate the value of PPPs to the world.

Renuka Gadde, vice president for global health at BD, commented that BD has extensive experience engaging in various types of PPPs—donating products, advocating, helping to strengthen a health system, or engaging in a shared value approach to solve a problem. The shared value model, which has a return on investment for all parties, is the approach that guides STRIDES. BD’s Mycobacterial Growth Indicator Tube is used to aid in specimen transport collection. Gadde repeated Piatek’s observation about the challenges of the infrastructure: India has 13,000 microscopy centers but only 55 laboratories with the appropriate analytic instruments. She explained that BD was interested in this particular partnership because USAID is a reliable partner with the ability to connect BD to the government of India. USAID has the capability to bring BD’s technology to bear to reverse TB health trends as long as training and learning continue, she emphasized.

Panel moderator Brenda Colatrella, associate vice president of corporate responsibility and president of the Merck Foundation, asked about the enabling conditions for STRIDES. Piatek explained that USAID had already established trust within India after having worked together for 7 years. Gadde added that it is important to have a FOCUSED approach: create a clear Framework of roles and responsibilities, maintain Open communication, address Conflicts of interest, Use partner strengths, provide Sustainability for the country after exiting the partnership, create an extensive Evaluation framework, and Deploy the right resources. Piatek emphasized the need for countries and their governments to take ownership of programs, which can be difficult when foreign service officers rotate in and have different approaches to the problem.

India readily accepted USAID’s blueprint, but Piatek recognized that there could be a need for increased oversight, communication, and monitoring in other countries. Gadde noted that raising awareness for and trust within any community can be challenging; in India, the partnership produced videos for the public about new policies, new drugs, and the stigma associated with the disease. Colatrella wondered if there was any resistance from the government. Piatek noted that it can be difficult for a country to recognize that it has a problem and to be receptive to external assistance. USAID’s and India’s approaches to building capacity differed and USAID had to compromise, losing a bit of time and resources in order to keep the partnership moving in the right direction. Gadde added that the bureaucracy of India is highly complex. She mentioned that a partnership with India would have been impossible without an intermediary such as USAID. In response to a question from Colatrella about the workforce needs for STRIDES, Gadde mentioned a need to train a large pool of laboratory technicians. To alleviate knowledge gaps, BD deploys experts from across the world. For STRIDES, these experts were brought together to attend training, and subsequent testing revealed that their knowledge levels doubled as a result.

Bruce Compton, senior director of international outreach for the Catholic Health Association of the United States, asked if USAID is developing capacity for partnership with another country. Piatek noted that building capacity in other countries could be more manageable because most have fewer laboratories than India. However, that also means that the teams sent to the next country could be smaller, thus making their jobs more difficult. USAID is not expanding this initiative quickly because it wants to ensure that it has the right partners. Katy Winckworth-Prejsnar of the National Comprehensive Cancer Network asked if aspects of this partnership could be replicated by other stakeholders, because the United Nations and USAID cannot be involved in every PPP. Gadde acknowledged that while those

agencies are typically involved in global health issues, who the partner is depends on the magnitude of the problem. UN methodologies could be adapted for new partnerships with other entities, Gadde said. Samuel Nixon, founder of humble1, LLC, pointed out that technology platforms could be used to make lessons learned more accessible for countries with similar problems. Clarion Johnson, private consultant, ExxonMobil, suggested industry-specific journals as another avenue to share these lessons.

THE PERSPECTIVES OF INTERMEDIARIES WORKING TO CREATE ENABLING CONDITIONS FOR PARTNERSHIPS

Keynote speaker Barbara Bulc, founder and president of Global Development, shared five ways to re-envision PPPs: (1) address health from a holistic perspective; (2) sense the interconnected systems (e.g., society, economy, and biosphere) of the SDGs; (3) remember the inequality gap—85 percent of people throughout the world cannot access clean water, affordable food, quality health care, or energy; (4) understand the connection between income and life expectancy; and (5) lead with compassion and courage. She pointed out that to improve the health care system, silos between disciplines and sectors need to be disrupted, and collective resources—beyond those of business and government—need to be harnessed. The first step to harnessing these collective resources is smart mapping of systems, stakeholders, issues, and finances. These maps then will be used to identify people with the compassion and courage to develop a partnership on a larger scale. Market insights are developed, and strategies are co-designed among several partners. The second step is to hold strategic meetings to share narratives, build trust, introduce internal organizational terminology, and develop greater attention and awareness. At this point, private and public investors could be identified, she continued. The third step is when transformation begins to take place, with the development of collaborative, sustainable, and scalable solutions. Bulc discussed the difference between “old power” (i.e., formal, evidence based, hierarchical, regulated, and slow) and “new power” (i.e., informal, local knowledge based, horizontal, unregulated, and fast) and encouraged the development of “next-generation partnerships” that combine the strengths of the two. Limited mindset and resistance to change are often barriers to transformational partnerships, she explained.

Omary Chillo, president of the Tanzania Health Summit, provided a brief history of Tanzania’s relationship with the private sector. After the Arusha Declaration in 1967, the government was solely responsible for the construction and management of health infrastructure. However, by 1991, after two decades of economic downturn and population increase, the private sector was allowed to support the government’s work. In 2009, private-sector participation in the health sector was formalized with the implementation of strategic policies. He noted that a barrier to achieving universal health care in Tanzania is the supply chain. Previously, the country’s Ministry of Health used its Medical Store Department as the primary supplier, which serves only 60 percent of health facilities. To address this problem, Chillo and his team engaged with a local nongovernmental organization, Prime Vendor, to support the remaining 40 percent. Prime Vendor is responsible for ensuring that any medication that the government cannot provide is available from the private sector. Availability of medication increased to 95 percent within only 5 years as a result of this partnership. There was a decrease in delivery time and an increase in order fulfillment, as well as an increase in purchase value for the private sector.

He also discussed service-level agreements for health care delivery PPPs. Even though faith-based organization hospitals were not originally part of the public sector, the government began to support them by providing funding for human resources and information systems. The private sector then provided support for 70 health learning institutions. However, he mentioned that private for-profit organizations are not often engaged in Tanzania, beyond supplying medical equipment, owing to government bureaucracy and a lack of trust.

Natalia Korchakova-Heeb, managing director of SDG.17 Consulting GmbH, described her company’s mission to translate the SDGs for health care infrastructure projects to assist developing countries in improving their health systems and infrastructure through PPP modalities and to identify digital solutions for health care in developing countries. “People-first PPPs” provide not only value for money but also value for people, she explained. The rationale for the application of PPPs varies: in developed countries it can be an issue of efficiency and cost saving, and in developing countries it can be the only possible option to develop critical infrastructure. The value chain for sustainable PPPs includes sustainable financing, which can diversify the sources of financing for health care PPPs to include actors such as impact investors and climate investors. In addition to sustainable financing, the PPP value chain includes sustainable architecture, construction, procurement, operation, and maintenance. She emphasized that it may become easier for governments to attract financing if it is clear how the partnership would address the SDGs.

She noted that health care PPPs serve as the instrument to achieve the sustainable development agenda with the following nine benchmarks: (1) address the needs of vulnerable groups by providing quality, efficiency, access, and affordability; (2) prioritize gender equality by consulting a gender specialist who understands men’s and women’s

unique health care needs in the design of hospitals and clinical trials; (3) design energy-efficient hospitals that consume less energy and also generate energy to the supply grid; (4) design resilient health care facilities for crisis response; (5) make health care facilities publicly accessible; (6) reach marginalized groups who often do not have access to digital solutions for health care; (7) focus on smart hospitals and urban health; (8) consider recycling medical, food, and other waste, in line with the principles of a circular economy; and (9) consult a climate expert to ensure that infrastructure is designed for resiliency, with climate risk in mind.

More non-infrastructure projects, such as information technology projects, product and development PPPs, and eHealth systems may emerge as a result of this approach toward achieving the SDGs. Korchakova-Heeb concluded by suggesting the development of a database that maps these PPP health care initiatives to encourage knowledge exchange.

Allison Goldberg, executive director of the AB InBev Foundation, asked the panelists how they facilitate courage and compassion in their leadership. Bulc talked about her experience with the International Federation of Pharmaceutical Wholesalers, which distributes approximately 90 percent of medications in the United States. This led to the development of a unique PPP between members of that association and Gavi, the Vaccine Alliance, to build capacity in Africa. Johnson shared the example of the Catholic Medical Mission Board, which has been investing between $400 million and $600 million in pharmaceuticals annually for nearly 23 countries. Korchakova-Heeb emphasized that PPPs need to be designed carefully and include stakeholders in the decision-making process. Doing so improves the public image of PPPs and ensures the communities’ support.

Mark Rasmussen, DAI Global Health, asked about other modalities that could be effective as neutral brokers to unite government, nongovernmental entities, and private-sector partners. Korchakova-Heeb referenced an initiative for a multi-stakeholder platform—PPPHealth4All—that provides methodology and training on how to create health care partnerships. Taylor asked how to motivate the private sector to engage in PPPs targeted toward vulnerable populations. Bulc said that the enabling environment would need to provide incentives, and corporate strategies would need to change. Bland emphasized that companies also need to change their perceptions about Africa—which is an expanding marketplace where investments could bring value to different stakeholders.

ROUNDTABLE DISCUSSION

Participants reflected on the workshop and presented topics for additional discussion. In response to a question from Taylor about existing PPP tools, Korchakova-Heeb said that the tools are primarily designed for infrastructure. They could be even more helpful if tuned specifically to health care PPPs and integrated with the SDG agenda, she continued. However, no matter how many tools exist, they cannot replace capacity building to train and retrain public officials and PPPs stakeholders. Muraya pointed out that because tools and methodologies become quickly outdated and are rarely presented clearly to end users, they often cannot be implemented usefully. Katembwe emphasized the need to adapt tools to a country’s unique situation. Compton reflected on whether there could be training to help ministries of health and finance better create an enabling environment for partnerships, and Bland emphasized the need to guide them to understand the connections among health care, disease prevention, education, and a vibrant economy. Vellenga expressed concern with the ability to scale up efforts, and he emphasized the need to think more deeply about the definition of partnership and associated risks. Geoffrey So, head of policy and partnerships at the Novartis Foundation, suggested that the patient play a larger role in discussions about PPPs. Center pointed out that informal partnerships are on the rise. He asserted that if a government incentivizes the private sector, the entire health system could benefit. ◆◆◆

DISCLAIMER: This Proceedings of a Workshop—in Brief was prepared by Linda Casola as a factual summary of what occurred at the meeting. The statements made are those of the rapporteur or individual workshop participants and do not necessarily represent the views of all workshop participants; the planning committee; or the National Academies of Sciences, Engineering, and Medicine.

The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published Proceedings of a Workshop—in Brief rests with the rapporteur and the institution.

REVIEWERS: To ensure that it meets institutional standards for quality and objectivity, this Proceedings of a Workshop—in Brief was reviewed by Richard Feiner, Weill Cornell Medicine, and Katherine A. Taylor, University of Notre Dame. Lauren Shern, National Academies of Sciences, Engineering, and Medicine, coordinated the review.

SPONSORS: This workshop was supported by AB InBev Foundation; Becton, Dickinson and Company; Bill & Melinda Gates Foundation; Catholic Health Association of the United States; ExxonMobil; Johnson & Johnson; Merck & Co., Inc.; Novartis Foundation; PATH; Procter & Gamble Company; Safaricom; United Nations Foundation; University of Notre Dame; UPS Foundation; and U.S. Centers for Disease Control and Prevention.

For additional information regarding the workshop, visit https://www.nationalacademies.org/event/10-23-2019/public-private-partnerships-for-global-health-at-the-national-municipal-and-community-levels-a-workshop.

Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2020. Public–private partnerships for global health at the national, municipal, and community levels: Proceedings of a workshop—in brief. Washington, DC: The National Academies Press. https://doi.org/10.17226/25904.

Health and Medicine Division

Copyright 2020 by the National Academy of Sciences. All rights reserved.