Professor Mitch 530a

Public–private partnerships (PPPs) in global health: the good, the bad and the ugly Arne Ruckerta* and Ronald Labontéb

aSchool of Political Studies, University of Ottawa, Canada; bFaculty of Medicine, University of Ottawa, Canada

Global Health Partnerships (GHPs) have become ubiquitous within glo- bal health governance (GHG). Even before the onset of the global financial crisis public–private partnerships (PPPs) were an omnipresent policy tool in global health and in the current austerity climate PPPs have been heralded as an effective way to address a growing resource gap in GHG. Despite their omnipresence, GHPs have not received ade- quate attention from critical scholars; few efforts have been made conceptually and theoretically to grasp how PPPs are transforming the logic of GHG. We argue that GHPs have contributed to the emergence of a complex global health governance architecture in which private solutions (market mechanism) are generally privileged over public approaches. Drawing on Gramscian conceptualisations of public/pri- vate, we suggest that the reshaping of the private and public realm inherent to PPPs represents a further deepening of the neoliberal man- agement of individuals and populations, allowing private interest to become more embedded within the public sphere and to influence global and national health policy making. This undermines the attempt to improve global health results as the inequitable distribution of social determinants of health, especially poverty and social exclusion, remain the main barriers to achieving health for all.

Keywords: global health; global governance; public–private partnerships; development effectiveness

Introduction Global Health Partnerships (GHPs) have recently become a central element of efforts to improve global health results. This is related to a rapid and remarkable shift in the global development assistance architecture, with the establishment of new aid mechanisms and global partnerships tasked with achieving specific disease control targets.1 A central feature of such partnerships is the cooperation between the private and the public sectors to achieve identified policy or

*Corresponding author. Email: [email protected]

© 2014 Southseries Inc., www.thirdworldquarterly.com

Third World Quarterly, 2014 Vol. 35, No. 9, 1598–1614, http://dx.doi.org/10.1080/01436597.2014.970870

programme goals in the health sector. Even before the onset of the global finan- cial crisis public–private partnerships (PPPs) had surfaced as an omnipresent pol- icy tool in global health.2 Under current budget conditions it is likely that they will play an ever more important role in global health governance (GHG). Given the prominence and further proliferation of PPPs as governance tools, it is sur- prising that GHPs have not received more attention by critical scholars, and that few efforts have been made conceptually and theoretically to grasp how PPPs are transforming the logic of GHG, as well as how they are reshaping and reconstitut- ing the boundaries between the public and the private realms of social activity.3

At first glance it might appear that the public is back in the driver’s seat, as full-scale privatisation efforts have been largely abandoned in the global health arena. Yet a more complex picture emerges once we look at the ways in which GHPs have created new forms of governance at the global and country levels, with the boundaries between what is considered public and private increasingly being blurred.4

In this article we first provide a historical backdrop to the emergence of PPPs in GHG and identify some of the central features of GHPs, discussing both positive and negative aspects of their operation. On the one hand, GHPs have helped to raise the profile of certain global health problems and contributed to generating additional resources and facilitating access to medication for impoverished popu- lations. On the other hand, GHPs have undermined efforts to better harmonise the delivery of aid and align donor activities, skewing national priorities of recipient countries by imposing those of donor partners. GHPs thus lead to an unnecessar- ily complex global governance architecture in which private solutions and mar- ket mechanisms are generally privileged over public approaches. We next assess the conceptual and theoretical implications of the proliferation of PPPs in GHG by comparing and contrasting different understandings of the intersection of private and public activity in global governance.

Drawing on Gramscian conceptualisations of public/private, we suggest that the reshaping of the private and public realm inherent to PPPs represents a further deepening of the neoliberal management of individuals and populations, allow- ing private interests to become embedded within the public sphere and to influ- ence global and national health policy making. We then situate PPPs as a tool of neoliberal GHG, and see in them a novel phase of the ongoing process of neolib- eralisation of GHG.5 We note that the focus on private sector-driven PPPs in global health ultimately undermines the attempt to significantly improve global health results as the inequitable distribution of social determinants of health, especially poverty and social exclusion, remain the main barriers to achieving health for all in the world today. In concluding, we discuss alternatives to current forms of PPP-driven GHG and suggest that to effectively address global health concerns would require a shift away from vertical forms of GHG inherent in most GHPs towards embracing an approach that focuses on addressing the inequitable distri- bution of social determinants of health (SDH) through progressive and equity- oriented public policy interventions and the reclaiming of public spaces. This implies conceptually a transition from GHG to Global Governance for Health, to ensure that health concerns are adequately taken into consideration in policy- making arenas not traditionally associated with global health, such as trade,

Third World Quarterly 1599

investment, employment, migration and other economic and social policy sectors.

The emergence of PPPs in GHG Until the early 1980s collaboration between the private and public sector to achieve global health results was minimal, with engagement generally limited to the realm of policy consultation with mostly nongovernmental organisations (NGOs).6 The bulk of development assistance in health originated from two sources: the World Bank and bilateral programmes from donor countries.7 The global health governance architecture was tightly controlled by powerful donor countries in concert with multilateral organisations, especially the World Health Organization (WHO), which remained the lead global health agency until the early 1990s. However, under the influence of neoliberal ideology and its associ- ated new public management principles, the relationship between the private and the public sectors started changing.8 International organisations, especially the Word Bank, began to champion a greater role for the private sector to collabo- rate in health-related development projects, as donors increasingly channelled funds through NGOs and private partners. In the early phase of neoliberal policy development (during the 1980s), most development actors promoted the ‘freeing of markets’ from the iron hand of government intervention. But the full-scale privatisation of health was abandoned by the mid-1990s, as even the most keen promoters of neoliberal solutions to global health problems, including the World Bank at that time, had to acknowledge that ‘where drugs are concerned, a pure market mechanism generally does not work...we are therefore not really speak- ing of creating a pure market situation, but a modified market mechanism incor- porating a whole series of safeguards to protect all the parties concerned’.9 Yet, at the same time, the WHO was being replaced by the international financial insti- tutions (IFIs), especially the World Bank and the IMF, as the central coordinating agencies of global health policy. The 1993 World Bank Report was seminal in establishing the World Bank’s dominance over WHO in global health policy development,10 and challenged the pre-eminence of the public sector by promot- ing greater private sector engagement.11 The WHO fully aligned itself with the IFI-driven global health agenda in the late 1990s as it launched a range of GHPs, including Roll Back Malaria in 1998 and the Stop TB Partnership in 1999. Rather than resist the tectonic shift in GHG underway in this period, the WHO reoriented and committed itself to becoming ‘more innovative in creating influ- ential partnerships…[because] the broad health agenda is too big for the WHO alone’,12 and to overcome obstacles to drug access ‘through improved coopera- tion between the public and private sectors’.13 With the WHO on board, GHPs mushroomed between 1998 and 2002, with more than 10 new partnerships annually, and close to 100 GHPs in operation by the mid-2000s.

Despite the widespread proliferation of PPPs in global health, there is little definitional clarity, with an abundance of terms used to describe different kinds of PPP, including Global Public Private Partnerships (GPPPs), Global Health Initia- tives (GHIs), International Public Private Partnerships for Health (IPPPHs), and Global Health Partnerships (GHPs). According to WHO, public–private alliances are understood as those partnerships which ‘bring together a set of actors for the

1600 A. Ruckert and R. Labonté

common goal of improving the health of a population through mutually agreed roles and principles’ and are seen as key to achieving lasting improvements in health on a global scale.14 In academic writing GHP has recently become the most commonly used term, defined as ‘relatively institutionalized initiatives, established to address global health problems, in which public and for-profit pri- vate sector organisations have a voice in collective decision-making’.15 GHPs vary across a range of functions: product development partnerships focus on the discovery and development of new drugs, vaccines, or other health products addressing neglected diseases and conditions in low- and middle-income coun- tries; partnerships involved in improvement of access to health products promote donations and discounted, subsidised and negotiated pricing of medications; public education, advocacy and research partnerships promote research and edu- cation around health issues predominantly affecting poor populations; global coordination partnerships represent alliances aimed at improving coordination among multiple efforts to achieve global health goals; partnerships focused on health service strengthening aim to improve infrastructure and systems for deliv- ery of health care; and regulation and quality assurance partnerships improve the regulatory environment and product quality.16

The mushrooming of GHPs has led to greater complexity in the GHG landscape as new actors and coordination structures have emerged. The traditional actors on the global health stage, most notably national ministries of health and the WHO, are being joined, and at times outright challenged, by an ever-greater vari- ety of private foundations and philanthropists, NGOs and for-profit corporations.17

This has meant a relative decline in importance and financial support for tradi- tional global health actors, and large increases in international support for novel partnerships and initiatives which have been emphasised, including by the WHO itself, as the most promising way forward in global health. In some cases the budgets of new global health actors rival that of multilateral organisations, with the Melinda and Bill Gates Foundation roughly matching WHO spending for the first time in 2007.18 The rise of new actors has also meant new challenges for the effective coordination of global health efforts, at a time when bilateral aid disbursements have increased substantially.19 Powerful GHPs operate in parallel to many multilateral organisations and directly compete for donor attention and resources. Global health governance has thus become more fragmented, uncoor- dinated and donor-driven.

GHPs and their added value in GHG (the good) Without doubt GHPs have had a marked and lasting impact on GHG. Not only have they raised awareness about pressing global health concerns and brought specific health issues on to the national and international policy agenda, they have also helped to mobilise new funding commitments to fight certain diseases, especially neglected infectious and tropical diseases, and to develop new health products. A number of product access GHPs have proven effective in supplying communities with drugs for free or at reduced cost, with the Global Alliance for Vaccine and Immunisation (GAVI) and Stop TB at the forefront of this effort. Some also suggest that GHPs have improved national health policy making through institutional reforms and health system strengthening,20 while others

Third World Quarterly 1601

note the contributions of GHPs to establishing norms and standards in treatment protocols, technical management and financial strategies.21

The way GHPs have stimulated new R&D in neglected areas and facilitated access to vaccinations are arguably their most significant contributions to global health, with more than 50 vaccines and 25 drugs manufactured or in develop- ment to address diseases predominantly affecting impoverished populations.22

As an example of this, the RotaTeq Nicaragua Partnership, a collaboration between Merck, the Nicaraguan Ministry of Health, local hospitals and a Tech- nical Advisory Group, played a key role in successfully implementing a rotavi- rus vaccination campaign in Nicaragua. According to an independent evaluation, the partnership demonstrated that a new rotavirus vaccine could be introduced rapidly in a developing country context, be successfully integrated into the exist- ing vaccine delivery infrastructure, and have a significant and measurable public health impact at the end of the three-year partnership.23 The HPV vaccine roll-out in Rwanda represents another success story. In this PPP Rwanda’s Ministry of Health partnered with Merck to offer the Gardasil HPV vaccine to all girls of appropriate age. Evaluations, again, suggest that this PPP was highly successful, in that 93.23% coverage was attained after the first three-dose course of vaccina- tion.24 To cite another example, a Gates Foundation funded-PPP brought together health workers in the Indian state of Andhra Pradesh and an international NGO to offer the Hepatitis B vaccine to the general public. The PPP focused not just on vaccine availability but also on strengthening the public health supply chain. The state health department was so impressed with the results that it took on responsibility for the $60 million (in 2004) annual costs of the programme, the PPP having served its catalytic purpose.25

But various cautions have been raised even about these success stories: what are the long-term costs of maintaining PPPs in product development, especially since many of the new technologies and resources favoured by PPPs are gener- ally more costly than less expensive interventions aimed at childhood diseases. And what will happen when free or subsidised vaccine-roll-outs end? Other studies have found that many PPPs emphasise private providers in the delivery of the selective interventions, where profit motives can reduce the pro-poor target- ing of such programmes.26 However, such concerns fade in comparison to some of the more substantial criticisms that have been raised in relation to GHPs.

GHPs and their negative impact on the global health and development agenda (the bad) It has been widely acknowledged that, for development assistance to be effec- tive, it must be delivered in a coherent, comprehensive and results-oriented fash- ion. In consequence, the 2005 Paris Declaration on Aid Effectiveness called for better alignment of aid with partner country priorities, systems and procedures in order to improve the effectiveness of aid interventions.27 In particular, the Declaration commits donors to use existing government structures when disburs- ing aid and to switch from project aid to general budget or sector-wide support, for example through the use of sector-wide approaches. Similar principles have also been at the heart of the Poverty Reduction Strategy Paper (PRSP) approach, the World Bank’s main policy coordination instrument, when it was first

1602 A. Ruckert and R. Labonté

introduced in the early 2000s, with health sector strategies expected to be aligned with national PRSPs and medium-term expenditure plans.28 At the same time as the Paris Declaration was finalised the global health community was working towards reaching a consensus on how to achieve greater coherence in division of responsibilities between different global institutions, and greater coordination of country level activities. As one example, the Global Task Team report on AIDS coordination among multilateral institutions discussed the need to improve collaboration and the division of labour between different global insti- tutions, based on a better understanding of their comparative advantage.29 How- ever, it is notable that until 2005 there was little acknowledgment of the importance of including GHPs in the effort to improve aid coordination and gov- ernance. Only then was the focus on the harmonisation agenda widened to include GHPs, as these were seen as reverting back to a project-driven approach to planning and priority setting in global development, where country policies were being imposed by powerful donors.30

Despite acknowledgement that poor aid harmonisation inhibits progress in global health, most GHPs have failed to harmonise their procedures and practices with one another and with other donors.31 Poor harmonisation has led to consid- erable duplication and waste, with the emergence of parallel systems for health service delivery among GHPs,32 and little alignment between recipient countries’ and GHP financial management systems.33 The case of the Global Fund and its AIDS programming is a good example of this, as national AIDS authorities have, at times, been competing with donor-driven Country Coordinating Mechanisms, and monitoring and evaluation requirements of AIDS programming are perceived as overly burdensome.34 Similarly, in several sub-Saharan African countries, the requirements for application and accountability inherent in GHPs sap much- needed resources in the health system.35 As one comprehensive study on the impact of GHPs notes: ‘There is a serious risk that weak human resource and sys- tems capacity at central and local levels may be overwhelmed by the prolifera- tion of multiple GHPs (and other HIV/AIDS initiatives), each with its separate demands’.36 Another study has documented how GHPs are, in fact, taking health worker time away from patient care in Tanzania, with almost half of a district medical officer’s time spent writing project reports to 11 different funders. Finally, requirements for specific bulk-buying through GHPs can weaken develop- ing countries’ public bulk-buying powers, raising the cost of essential medi- cines.37 This shows that non-alignment between GHPs and recipient governments’ existing mechanisms and policies may undermine the effectiveness of global health programming.

Most GHPs are by design issue-specific and focus on narrow and targeted ver- tical interventions to address infectious diseases, with little regard for the wider (health systems) implications of their operation. This has led to a growing seg- mentation of health financing, with the emergence of disease silos in GHPs. A recent study of philanthropic organisations which are behind many global health PPPs reveals that the vast majority of funding is directed to infectious diseases. For example, the Gates Foundation’s focus has been on developing medical technologies, with more than 97% of its financial disbursements directed at infectious diseases, and less than 3% to non-communicable diseases (NCDs).38

This is typical for most GHPs, with more than 75% of all GHP funding targeted at

Third World Quarterly 1603

infectious diseases.39 Yet, in every region except sub-Saharan Africa, NCDs now far outpace the burden of infectious disease, with the burden of NCDs accelerat- ing rapidly.40 At the same time the most common killer of children in Africa remains easily treatable diarrhoeal diseases that are the direct outcome of pov- erty.41 Moreover, there is no emphasis in most GHPs on the role that SDH play in the distribution of the global disease burden, even in the case of infectious dis- eases (which are rarely studied through an SDH lens). A recent WHO report notes that there is a strong socioeconomic gradient for tuberculosis (TB), both across and within countries. Poor and vulnerable social groups are more at risk of TB as a result of factors that include malnutrition, crowding, HIV/AIDS, smoking, alcohol abuse, indoor air pollution, and poor access to health services.42 Yet GHPs dealing with TB have largely neglected the role of SDH in the contraction and transmission of the disease. This is even more problematic as traditional TB control strategies are successful in reducing death rates and prevalence but less effective in reducing incidence. Consequently, further progress in TB control in many settings will require additional preventive measures, in particular targeting proximate TB risk factors, such as crowding and malnutrition, and their social and economic determinants, including poverty and poor living conditions.43 Yet a comprehensive review of GHPs has found that, while most GHPs have equity objectives, they tend to lack explicit pro-poor operational approaches, or robust measures to provide evidence of benefit to the very poorest people.44

Because of the magnitude of funding there is a growing interest in the effects of GHPs on health system strengthening (HSS), with the early absence of focus on HSS representing another noted weakness of most GHPs. Although some GHPs, notably the Global Fund, are now giving limited attention to HSS, much of this so-called ‘diagonal approach’, in which vertical programmes attempt to address horizontal health system needs, usually concern only single disease interven- tions.45 The horizontal strengthening primarily takes the form of training for delivery of specific therapies or programmes, and invariably takes limited resources from generic public health systems to disease silos. Other concerns expressed about GHPs are the unintended negative effects of disease-specific verti- cal programmes. This includes whether they undermine efforts to improve donor harmonisation and alignment between donors and recipient government policies and programmes, place increased burdens on already weak health systems and unintentionally weaken the delivery of services for non-focal diseases.46 Accord- ingly, a recent assessment of the impact of GHPs on HSS concluded that ‘while some organisations have augmented funding for HSS, aggregate donor commit- ments do not match the rhetoric surrounding the issue’.47 This shows that, while there is recognition of the importance of HSS, in practice most GHPs still do not direct significant resources at it.

There have been some efforts to improve aid effectiveness through better alignment, for example through the International Health Partnership (IHP+). The intent of these initiatives is to apply principles of the Paris Declaration on Aid Effectiveness to the health sector. Findings from the Results Group evaluation of IHP+ reports some progress, including more health aid in programmes rather than projects, more aid recorded on government budget, and more multiyear commitments.48 There have also been incremental improvements in the strengthening of national planning processes and principles around mutual

1604 A. Ruckert and R. Labonté

accountability, and some progress in development partners aligning their support with national budgets. But there is a lack of progress in the use of countries’ financial management and procurement systems, and in the integration of dupli- cative performance reporting frameworks and information systems.49 As a whole, then, there has not been the ‘step change’ in aid effectiveness that was anticipated when IHP+ was launched. And aid recorded on budget is not the same as general budget support, where the external funds are used to finance overall public health programming. A recent study of health aid for the so-called 74 Countdown Countries – the ones lagging behind on the Millennium Develop- ment Goals (MDGs) – found that the amount going to general budget support or to overall general health and health systems has actually declined since 2003 (from around 40% to just under 24%), with funding tied to HIV, malaria, nutri- tion, immunisation and other vertical programmes increasing,50 thus undermin- ing efforts to increase aid effectiveness through better alignment.

What is more, the availability of substantial amounts of new GHP funding – particularly through the Global Fund – raises serious questions about sustainabil- ity, and possibly also macroeconomic stability. Although not particularly large in terms of the overall financing of health services, GHP resources are often highly significant at the country level.51 There is a risk that country spending patterns will be dictated by the GHPs and the need to sustain the activities and services provided by them, rather than by domestically established priorities and policies. The cancellation of Round 14 of Global Fund financing is a case in point. After international donors started to drastically reduce contributions to the Fund in the wake of the global financial crisis, in November 2011 the Global Fund announced that it would make no new grants until 2014, in large part because of depressed donations attributed to the global financial crisis.52 This is related to more than $2 billion of pledges that have either not been paid by indi- vidual donors or were not disbursed in time. More than 70% of life-saving AIDS medicine in the developing world, and about 85% of TB programmes in Africa, are financed by the Global Fund.53 In response, the Fund has introduced a Tran- sitional Funding Mechanism for essential programming since 2011 to ensure sustainability of vital health programming. More recently it introduced a com- pletely new funding model that replaces the old rounds-based approach with a more flexible allocation model and disbursement timeline. But under this new model countries and programmes can only be funded by invitation, thus limiting access to funds to pre-selected countries, further raising questions about better alignment and country ownership of GHP programmes and policies.54 What is clear is that the issue of sustainability, the need for predictability and the ‘fit’ of GHP funds and donations with medium-term expenditure frameworks and national macroeconomic policies require more rigorous study and debate.55

Another area of concern surrounding GHPs relates to the way in which they are governed, and the role that private interests play in their decision-making and policy-development processes. An analysis of 23 PPPs in global health found that, tied with university researchers, most of the decision makers were from the corporate sector.56 Even the Global Fund, perhaps the most transparent and nim- ble or learning-styled of the GHPs, and the one with the most equitable gover- nance structure, still allocates two of 24 board positions (or over 8%) to the private sector and the Gates Foundation, respectively, despite their combined

Third World Quarterly 1605

contributions since 2001 amounting to 6%. The under-representation of constitu- encies from low- and middle-income countries on GHP governing bodies is another key concern, with an average of only 17% of the membership represent- ing low- and middle-income countries in a sample of 23 GHPs.57

The way in which GHPs are driven by the role of philanthropic donations in global health is another area of concern. These philanthropic organisations and their organisational structures have been little studied. However, a pioneering analysis of institutional relationships in global health philanthropy documents the central role that private corporations have played in setting the policy direc- tion of many GHPs.58 The study reveals the close relationships between CEOs of for profit corporations and the board of directors of the various philanthropic foundations that fund GHPs. As one example the study highlights the existence of large potential conflicts of interest among the largest foundation in global health, the Bill and Melinda Gates Foundation. This is linked to the foundation’s substantial holdings in the Coca-Cola Corporation, while at the same time it par- ticipates in grants that encourage communities in developing countries to become business affiliates of Coca-Cola,59 despite the knowledge that sugary drinks such as those produced by Coca-Cola are correlated with the rapid increase in obesity and diabetes in developing countries.60 This conflict of inter- est might somewhat explain the bias in focus on infectious diseases among GHPs, even though NCDs now constitute more than half of all deaths in low- and mid- dle-income countries.

Such findings confirm the results of an earlier study which suggests that, for corporations, partnerships have increased their influence in policy making at both the global and national level; brought direct financial returns, such as tax breaks and market penetration, as well as direct financial benefits through brand and image promotion; and enhanced corporate authority and legitimacy through association with the UN and other bodies.61 In this context it is important to note that co-opting health efforts towards private sector goals is nothing new in the global health arena.62 In the early 20th century the Rockefeller Foundation was seen by some as a means to placate critics of large oil corporations,63

while the tobacco industry’s practice of ‘white coating’, ie drawing on the respectability and goodwill of medical research and healthcare provision, is well documented.64 Recent analysis suggests that large food and beverage corpora- tions are now adopting similar tactics through global health PPPs, with the potential to derail the public health agenda surrounding the link between nutri- tion and obesity.65 Notable examples include partnerships between the Coca- Cola Company and Save the Children, Cadbury and UNICEF, and Hershey and the American Cancer Society. Such partnerships also help with corporate lobby efforts and represent an opportunity for corporations to improve their public image and demonstrate corporate social responsibility. In the case of Coca-Cola, CEO Sandy Douglas leveraged the company’s relationship with the American Academy of Family Physicians to help make the case that soda taxes were unnecessary, while Save the Children subtly changed its own position away from lobbying for soda taxes, arguing that support of soda taxes did not fit the way Save the Children works any more.66 It is doubtless not a coincidence that it is seeking a grant from Coca-Cola and has accepted a $5 million grant from PepsiCo.

1606 A. Ruckert and R. Labonté

This ‘double game’ of corporations donating money after disrupting commu- nities through the negative health impact of their products, can distort the public health agenda, especially as the share of private company support of overall glo- bal health funding increases.67 There is some evidence that WHO and other multi- lateral agencies are beginning to worry about the companionship with private companies inherent in many GHPs. Reflecting arguments from civil society groups about the too cosy relationship between entrepreneurial firms and the mandate of the WHO, a 2012 cautionary comment about PPPs on the WHO website itself notes that:

Public agencies clearly benefit from working in collaboration with the private sec- tor in areas where the public sector lacks expertise and experience, eg in product development, production process development, manufacturing, marketing and dis- tribution. However, there are areas, such as public health policy-making and regu- latory approval, where the concept of partnership with for-profit enterprise is not appropriate.68

Global health PPPs and the neoliberalisation of GHG (the ugly) How, then, can we theoretically and conceptually grasp GHPs and their rapid expansion in the early 2000s and assess their impact on GHG? While there has been some discussion among scholars about the changing relationship between private and public forms of authority in global governance, most accounts, on the one hand, focus on the rise of private actors and the entrenchment of private authority in global governance regimes, discussed in terms of the privatisation of world politics.69 On the other hand, recent theoretical interventions have started to focus on how PPPs are affecting the public dimension of global gover- nance, understanding the public domain as a form of public practices that are culturally specific and temporally bounded.70 Drawing predominantly on the Copenhagen School, such interventions suggest that understanding the public sphere as a social totality instantiated through ongoing practices enables us to examine the complexities of shared governance arrangements in which multiple actors, objects and subjects become materially reassembled and discursively reconstituted.71 What both attempts to grasp the recent transformation of global governance have in common is how they conceptualise the private and public sector as spheres that are assumed to exist independently of each other. Follow- ing this, analysts then attempt to identify the impact of changes in governance forms on either the public or the private dimension of global governance. How- ever, to discuss global (health) governance in terms of neatly separable and dis- tinct social spheres of public and private activity is to commit the liberal sin of reification.

Drawing on Gramscian political economy, we conceptualise global gover- nance arrangements not as a sum of their separate public and private parts but rather as a social totality in which the private sphere is circumscribed by the public realm, but through PPPs is expanding outwards to absorb an ever larger share of the public sphere (Figure 1). The social relationist ontology at the heart of such a conceptualisation allows for a better understanding of the mutual constitution of separate spheres of activity in global governance. To put it

Third World Quarterly 1607

differently, most private activity in capitalist society is dependent on public authority, with the protection of property rights a prominent example, and the extent to which private activity is encouraged hinges upon the regulation of markets.

For example, deregulation of financial markets is itself a form of public (re-) regulation that allows private actors to absorb a larger share of the public sphere and to play a more formal role in the rule-setting process, with potentially far- reaching negative consequences, as demonstrated by the global financial crisis of 2008. Hence, PPPs can neither be understood as a privatised form of advanced neoliberal governance, nor as a completely novel practice in the public domain. Rather, PPPs must be conceived as the rearranging of the boundaries between the public and private sphere, and as a political effort to further entrench private interests within an ever shrinking public sphere. Thus, PPPs are part of the (ongoing) neoliberalisation process of global health and its governance, repre- senting changing expressions of neoliberal governance forms.72 With full-scale privatisation of health off the global agenda by the early 2000s, the embrace of public–private partnerships in global health allowed corporations to maintain their influence in global health and expand into new markets and connect with new consumers globally. The use of markets in the delivery of medications and vaccinations, promoted in many PPPs, continues the trend towards commodifica- tion of health services that has been part of the neoliberal turn in health governance since the early 1980s.

In this context it must be noted that, particularly in the USA, tax breaks afforded to private foundations amount to a public subsidy of their budgets and expenditure. In the USA it is estimated that 45% of the $500 billion that foun- dations hold actually ‘belongs to the American public’ in the sense that it is money foregone by the state through tax exemptions.73 Thus, while almost half the private foundation funds are actually public money, there is little to no public oversight of how the money is spent. Rather the reverse: because of the

Public Sector

PPP

Private Sector

Figure 1. Co-constitution of public and private sector.

1608 A. Ruckert and R. Labonté

resources available to philanthropic foundations, they can exert significant influ- ence over national and global health policy agendas. For the Bill and Melinda Gates Foundation the public tax expenditure is fairly low, amounting to only 9% of their contributions, according to their Foundation’s website. Nevertheless, that amounts to a government contribution of $2.2 billion, again with little gov- ernment or public oversight of the decisions the Foundation makes – and cer- tainly with no diminishing of the influence Bill Gates personally exerts over the global health agenda. This elite power is used to reinforce the biomedical approach to global health and to ensure that private corporations play a central role in the identified solutions. Because specific companies and industries partic- ipate in PPPs, these partnerships tend to favour technical approaches and vertical programmes with their attendant problems, reinforcing the biomedical approach to health issues that is at the heart of neoliberal global health governance.74 The influence of philanthropic organisations and private corporations on the global health agenda might also partly explain the absence of the social determinants of health approach from most GHPs. The problematic agenda-setting power of well endowed GHPs is further evident in the way in which they combine access to significant material resources with their central role in global health gover- nance processes and their ideational fit with dominant neoliberal theories and ideology about the efficiency of the private sector and the superior role of the market in delivering goods and services.75 The scale of resources (both in terms of physical and social capital) available to most GHPs means that their presence within high-level decision-making circles in global health has gradually become institutionalised. In this process GHPs have become widely accepted as legitimate decision-making bodies in GHG, despite lacking proper democratic legitimacy and accountability.

Conclusion: reinvigorating public spaces through global governance for health After tracing the emergence of PPPs in global health governance, this article has identified some of the positive as well as negative aspects of the operation of GHPs. Even supporters of GHPs acknowledge that they have not yet resolved many of the issues identified since the very beginning of their operation, includ- ing poor alignment, high transaction costs, poor democratic accountability and governance, a narrow focus on infectious diseases and biomedical interventions, and resource predictability.76 However, if we are serious about reducing the glo- bal disease burden, we need to go further than improving GHPs. What is required is acknowledgment of the role of social determinants of health, and how global governance arrangements in areas other than health (eg trade, intellectual prop- erty rights, debt, labour standards, etc) affect the social determinants and rein- force existing health inequities. This implies that GHG be turned away from market-oriented forms of vertical and disease-specific interventions towards a coherent and equity-oriented system of global governance for health (GGFH). The concept of GGFH captures the need to extend analysis beyond the traditional spaces in which GHG is enacted, and is concerned not only with institutions and practices specifically created to address health determinants, but also with any institutions and practices that have a substantial impact on social determinants of health. Since health policy and outcomes are increasingly affected by policy

Third World Quarterly 1609

decisions in areas as diverse as trade, the environment and finance, new forms of governance are required that facilitate multi-sectoral and multilevel action and propel the SDH agenda to the forefront of global governance practices.77

Finally, one of the key questions to be asked about GHPs is why we need them in the first place. As Sania Nishtar commented a decade ago, the presumed need for PPPs ‘arose against the backdrop of inadequacies on the part of the pub- lic sector to provide public goods on their own…owing to a lack of resources and management issues’.78 This in turn raises the issue of why there are not enough public resources to address global health concerns without having to rely on philanthropic or corporate contributions. While PPPs are seen as the best way forward to mobilise additional resources, it is obvious that the need to rely on the private sector has to do with how neoliberal policy reforms have led to a sharp decline in government revenue in many countries, undermining state capacity to deal with health problems and questions of distributive justice. Using figures from the World Bank Data Set, between 2002 and 2010 the monetised value of global taxation (which remained at roughly 14% of global GDP over this period) went from US$4.8 to $8.9 trillion. But the value of global GDP over this same period swelled from $33.4 trillion to $63.2 trillion, representing a doubling of the amount of global wealth in private hands over just this nine year period. These are crude data, since there remain high-tax and high-public spend coun- tries, and low-tax and very little public-spend countries. But since we are con- cerned with the global dimensions of health, a global rough average presents a disturbing picture in which taxation for public goods has fallen well behind the accumulation of private capital. As pointed out earlier, PPPs are themselves con- tributing to this problem by the nature of their affiliation with philanthropic or- ganisations that undermine the revenue base of governments through tax deductions.

But issues of distributive justice must also be raised at the global level. Vari- ous policy proposals have recently been under discussion to create new revenue streams for global health, with one concrete proposal with potentially major con- sequences for global health funding – the financial transaction tax (FTT) – under discussion in a variety of global policy fora (EU, G20, etc). Such a tax could easily address the resource gap (around $500 billion) that has been identified to achieve all the health-related MDGs by 2015.79 Support for the FTT gained a foot- hold in several EU countries in the wake of the financial crisis, though less for global health purposes than to support the costs of having bailed out failing investment banks. Nonetheless, the practicality of using taxes to fund global health initiatives has been demonstrated by the successes of other innovative taxes to support global health programming, for example the aviation tax to fund the International Drug Purchasing Facility (Unitaid). A global governance system that aims to improve health results across the income spectrum must ulti- mately be informed by the explicit inclusion of ethical considerations through greater attention to global distributive justice in all aspects of global governance, particularly global economic governance. This requires modification of the upstream forces on health, including the rules governing the global economy that fail to alleviate poverty, promote equity and improve institutional capacity in developing countries.80 Only through a wholesale abandonment of neoliberal

1610 A. Ruckert and R. Labonté

global governance (as inherent in most GHPs) can the structural root causes of poor health be addressed.

Competing interests The authors declare that they have no competing interests.

Acknowledgment Ronald Labonté is supported through the Canada Research Chair program of the Government of Canada.

Notes on Contributors Arne Ruckert is Senior Research Associate in the Faculty of Medicine and Part- Time Professor in the School of Political Studies at the University of Ottawa. His principal areas of research include the international financial institutions and the international aid architecture, the financial crisis and health equity, global health governance and health diplomacy, and the impact of trade agreements on health. He has co-edited Post-Neoliberalism in the Americas (Palgrave, 2009) and published on development and health issues in a wide array of academic journals. He also engages in development and global health policy consulting for government and non-governmental clients.

Ronald Labonté is Canada Research Chair in Globalization and Health Equity and Professor in the Faculty of Medicine, University of Ottawa. His current research interests include globalization as a ‘determinant of determinants’ (he chaired the Globalization Knowledge Network for the WHO Commission on Social Determinants of Health; see www.globalhealthequity.ca); ethics, human rights and global health development; global migration of health workers; revi- talization of comprehensive primary health care; and global health diplomacy. He has around 200 scientific publications and several hundred articles in popular media. His recent books include Globalization and Health: Pathways, Evidence and Policy (Routledge, 2009); Health Promotion: From Community Empower- ment to Global Justice (Palgrave Macmillan. 2008); and Critical Public Health: A Reader (Routledge. 2007).

Notes 1. Brugha, “Global Health Initiatives.” 2. Buse and Walt, “Global Public–Private Partnerships: Part 1.” 3. Except for Rushton and Williams, Partnerships and Foundations. 4. Best and Gheciu, The Return of the Public in Global Governance. 5. Peck and Tickell, “Neoliberalizing Space.” 6. Buse and Walt, “Global Public–Private Partnerships: Part I.” 7. Brugha, “Global Health Initiatives.” 8. Buse and Walt, “Global Public–Private Partnerships: Part I.” 9. Dukes, “The Contribution of the Private Sector,” 74. 10. Brugha, “Global Health Initiatives.” 11. World Bank , World Development Report 1993. 12. Brundtland, “WHO.” 13. Buse and Walt, “Global Public–Private Partnerships: Part I,” 555. 14. Kickbusch and Quick, “Partnerships for Health,” 70. 15. Buse and Harmer, “Seven Habits,” 259.

Third World Quarterly 1611

16. Buse and Walt, “Global Public–Private Partnerships: Part I.” 17. Szlezak et al., “The Global Health System.” 18. McCoy et al., “The Bill & Melinda Gates Foundation’s Grant-making Programme.” 19. Brugha, “Global Health Initiatives.” 20. Caines and Lush, Impact of Public–Private Partnerships. 21. Druce and Harmer, The Determinants of Effectiveness. 22. Kickbusch and Quick, “Partnerships for Health.” 23. Khawaja et al., “Evaluating the Health Impact of Public–Private Partnership.” 24. Binagwaho et al., “Achieving high Coverage.” 25. McKinsey and Company, “Building Effective Public Private Partnerships.” 26. Malmborg et al., “Can Public–Private Collaboration Promote Tuberculosis Case Detection?” 27. “Paris Declaration on Aid Effectiveness.” 28. Buse and Harmer, “Seven Habits.” 29. Shakow, “Global Fund – HIV/AIDS Programs.” 30. Brugha, “Global Health Initiatives.” 31. “Paris Declaration on Aid Effectiveness.” 32. McKinsey and Company, “Building Effective Public Private Partnerships.” 33. Casper, “Updated Discussion Paper.” 34. Carlson, Assessing the Impact of Global Health Partnerships. 35. Conway et al., “Building Better Partnerships.” 36. Caines et al., Assessing the Impact, 5. 37. Carlson, Assessing the Impact of Global Health Partnerships. 38. Stuckler et al., “Global Health Philanthropy.” 39. Nishtar, “Public–Private Partnerships for Health.” 40. Lins et al., “New Frontiers.” 41. Muula, “Will Africa Achieve the Millenium Development Goals?” 42. World Health Organization, Closing the Health Equity Gap. 43. Ibid. 44. Conway et al., “Building Better Partnerships.” 45. Martins et al.,“Did the First Global Fund Grant (2003–2006) Contribute?” 46. WHO Maximizing Positive Synergies Collaborative Group, “An Assessment of Interactions.” 47. Hafner and Shiffman, “The Emergence of Global Attention,” 48. 48. Shorten et al., “The International Health Partnership Plus.” 49. Ibid. 50. Hsu et al., “Countdown to 2015.” 51. Conway et al., “Building Better Partnerships.” 52. Ooms and Hammonds, “Global Governance of Health.” 53. York, “Economic Crisis hits Health Aid.” 54. The Global Fund, CCM Newsletter. 55. Conway et al., “Building Better Partnerships.” 56. Overseas Development Institute, Global Health. 57. Kickbusch and Quick, “Partnerships for Health.” 58. Carlson, Assessing the Impact of Global Health Partnerships. 59. Ibid. 60. Conway et al., “Building Better Partnerships.” 61. Buse and Walt, “Global Public–Private Partnerships: Part II.” 62. Shah, “Corporate Philanthropy and Conflicts of Interest.” 63. Holcombe, Writing off Ideas. 64. Buse and Walt, “Global Public–Private Partnerships: Part II.” 65. Brownell and Warner, “The Perils of Ignoring History.” 66. Freedhoff and Hébert, “Partnerships.” 67. Buse and Walt, “Global Public–Private Partnerships: Part II.” 68. Muula, “Will Africa Achieve the Millennium Development Goals?” 69. For example, Hall and Biersteker, The Emergence of Private Authority. 70. For example, Abrahamson and Williams, “Security beyond the State.” 71. Best and Gheciu, The Return of the Public in Global Governance. 72. Peck and Tickell, “Neoliberalizing Space.” 73. McCoy et al., “Global Health Funding.” 74. Ng and Ruger, “Global Health Governance.” 75. Rushton and Williams, Partnerships and Foundations. 76. Committee for Development Policy, Implementing the Millennium Development Goals. 77. Labonté et al., Globalization and Health. 78. Nishtar, “Public–Private Partnerships,” 1. 79. Action for Global Health, Financial Transaction Taxes. 80. Benatar et al., “Values in Global Health Governance.”

1612 A. Ruckert and R. Labonté

Bibliography Abrahamson, R., and M. C. Williams. “Security beyond the State: Global Security Assemblages in Interna-

tional Politics.” International Political Sociology 3, no. 1 (2009): 1–17. Action for Global Health. Financial Transaction Taxes: A Crucial Tool to Meet the Health MDGS. Accessed

May 6, 2013. http://www.aidsalliance.org/includes/document/FTTHealth.pdf. Benatar, S. R., G. Lister, and S. C. Thacker. “Values in Global Health Governance.” Global Public Health 5,

no. 2 (2010): 143–153. Best, J., and A. Gheciu, eds. The Return of the Public in Global Governance. Cambridge: Cambridge Univer-

sity Press, 2013. Binagwaho, A., C. M. Wagner, M. Gatera, C. Karema, C. T. Nutt, and F. Ngabo. “Achieving High Coverage

in Rwanda’s National Human Papillomavirus Vaccination Programme.” Bulletin of the World Health Organization 90, no. 8 (2012): 623–628.

Brownell, K. D., and K. E. Warner. “The Perils of Ignoring History: Big Tobacco Played Dirty and Millions Died – How Similar is Big Food?” Milbank Q 87, no. 1 (2009): 259–294.

Brugha, R. “Global Health Initiatives and Public Health Policy.” In International Encyclopedia of Public Health, edited by Stella Quah, 72–81. Oxford: Academic Press, 2008.

Brundtland G. H. “WHO – The Way Ahead.” Statement by the Director-General to the 103rd Session of the Executive Board. Geneva, January 25, 1999.

Buse, K., and A. M. Harmer. “Seven Habits of highly Effective Global Public-Private Health Partnerships: Practice and Potential.” Social Science & Medicine 64, no. 2 (2007): 259–271.

Buse, K., and G. Walt. “Global Public-Private Partnerships: Part I – A New Development in Health?” Bulletin of the World Health Organization 78, no. 4 (2000): 549–561.

Buse, K., and G. Walt. “Global Public-Private Partnerships: Part II – What are the Health Issues for Global Governance?” Bulletin of the World Health Organization 78, no. 5 (2000): 699–709.

Caines, K., K. Buse., C. Carlson, R.-M. Loor, N. Druce, C. Grace, M. Pearson, J. Sancho and R. Sadanandan. Assessing the Impact of Global Health Partnerships. London: DFID Health Resource Centre, 2005.

Caines, K., and L. Lush. Impact of Public-Private Partnerships addressing Access to Pharmaceuticals in Selected Low- and Middle-Income Countries: A Synthesis Report from Studies in Botswana, Sril Lanka, Uganda, and Zambia. Geneva: Initiative on Public-Private Partnerships for Health, 2004.

Casper, T. “Updated Discussion Paper on the Core Business Model of a Mature Global Fund.” Paper presented at the ninth board meeting of the Global Fund, Arusha, November 18–19, 2004.

Carlson, C. Assessing the Impact of Global Health Partnerships: Country Case Study Report. London: DFID Health Resource Centre, 2004.

Committee for Development Policy. Implementing the Millennium Development Goals: Health Inequality and the Role of Global Health Partherships. New York: United Nations, 2009.

Conway, M. D., S. Gupta, and S. Prakash. “Building Better Partnerships for Global Health.” McKinsey Quar- terly (2006): 1–8.

Druce, N., and A. Harmer. The Determinants of Effectiveness: Partnerships that Deliver Review of the GHP and ‘Business’ Literature. London: DFID Health Resource Centre, 2004.

Dukes, G. “The Contribution of the Private Sector: An Introduction.” Australian Prescriber 20 (1997): 74–75. Freedhoff, Y., and P. C. Hébert. “Partnerships between Health Organizations and the Food Industry risk Derail-

ing Public Health Nutrition.” Canadian Medical Association Journal 183, no. 3 (2011): 291–292. Hafner, T., and J. Shiffman. “The Emergence of Global Attention to Health Systems Strengthening.” Health

Policy and Planning 28 (2013): 41–50. Hall, R. B., and T. J. Biersteker eds. The Emergence of Private Authority in Global Governance. Cambridge:

Cambridge University Press, 2002. Holcombe, R. G. Writing off Ideas: Taxation, Foundations, and Philanthropy in America. New Brunswick, NJ:

Transaction Publishers, 2000. Hsu, J., C. Pitt, G. Greco, P. Berman, and A. Mills. “Countdown to 2015: Changes in Official Development

Assistance to Maternal, Newborn, and Child Health in 2009–10, and Assessment of Progress since 2003.” Lancet 380, no. 9848 (2012): 1157–1168.

Khawaja, S., A. Cardellino, D. Klotz, B. J. Kuter, M. B. Feinberg, B. D. Colatrella, and T. C. Mast. “Evaluat- ing the Health Impact of a Public-Private Partnership: To Reduce Rotavirus Disease in Nicaragua.” Human Vaccines & Immunotherapeutics 8, no. 6 (2012): 777–782.

Kickbusch, I., and J. Quick. “Partnerships for Health in the 21st Century.” World Health Statistics Quarterly 51, no. 68 (1998): 68–74.

Labonté, R., T. Schrecker, C. Packer, and V. Runnels eds. Globalization and Health: Pathways. Evidence and Policy. New York: Routledge, 2009.

Lins, N., C. Jones, and J. Nilson. “New Frontiers for the Sustainable Prevention and Control of Non-communi- cable Diseases: A View from Sub-Saharan Africa.” Global Health Promotion 17, no. 27 (2010): 27–30.

McKinsey and Company. “Building Effective Public Private Partnerships: Lessons Learned from the Jordan Education Initiative.” 2005. http://www.weforum.org/pdf/JEI/JEIreport.pdf.

Third World Quarterly 1613

Malmborg, R., G. Mann, R. Thomson, and B. Squire. “Can Public-Private Collaboration Promote Tuberculosis Case Detection among the Poor and Vulnerable?” Bulletin of the World Health Organization 84, no. 6 (2006): 752–758.

Martins, J. S., A. B. Zwi, and P. M. Kelly. “Did the First Global Fund Grant (2003–2006) Contribute to Malaria Control and Health System Strengthening in Timor-Leste?” Malar J 11, no. 237 (2012): 1–10.

McCoy, D., S. Chand, and D. Sridhar. “Global Health Funding: How Much, Where it Comes from and Where it Goes.” Health Policy and Planning 24, no. 6 (2009): 407–417.

McCoy, D, G. Kembhavi, J. Patel, and A. Luintel. “The Bill & Melinda Gates Foundation’s Grant-making Programme for Global Health.” Lancet 373, no. 9675 (2009): 1645–1653.

Muula, A. S. “Will Africa Achieve the Millennium Development Goals?” Croatian Medical Journal 47, no. 1 (2006): 194–196.

Nishtar, S. “Public–Private ‘Partnerships’ in Health – A Global Call to Action.” Health Research Policy and Systems 2, no. 5 (2004): 1–7.

Ng, N., and J. Ruger. “Global Health Governance at a Crossroads.” Global Health Governance 3, no. 2 (2011): 1–37.

Ooms, G., and R. Hammonds. “Global Governance of Health and the Requirements of Human Rights.” Global Policy 3, no. 4 (2012): 476–479.

Overseas Development Institute. Global Health: Making Partnerships Work. London: Overseas Development Institute, 2007.

“Paris Declaration on Aid Effectiveness: Ownership, Harmonisation, Alignment, Results and Mutual Account- ability.” In The Paris Declaration on Aid Effectiveness and the Accra Agenda for Action. Paris: OECD, 2005.

Peck, J., and A. Tickell. “Neoliberalizing Space.” Antipode 34, no. 3 (2002): 380–404. Rushton, S., and O. D. Willaims eds. Partnerships and Foundations in Global Health Governance. London:

Palgrave Macmillan, 2011. Shah, N. K. “Corporate Philanthropy and Conflicts of Interest in Public Health: Exxonmobil, Equatorial Gui-

nea, and Malaria.” Journal of Public Health Policy 34, no. 1 (2012): 121–136. Shakow, A. “Global Fund–World Bank HIV/AIDS Programs: Comparative Advantage Study.” 2006. http://www.

cgdev.org/doc/event%20docs/2.7.06%20HIV/GFWBReportFinalVersion.pdf. Shorten, T., M. Taylor, N. Spicer, S. Mounier-Jack, and D. McCoy. “The International Health Partnership Plus:

Rhetoric or Real Change? Results of a Self-reported Survey in the Context of the 4th High Level Forum on Aid Effectiveness in Busan.” Globalization and Health 8, no.13 (2012): 1–13.

Stuckler, D., S. Basu, and M. McKee. “Global Health Philanthropy and Institutional Relationships: How should Conflicts of Interest be Addressed?” PLOS Medicine 8, no. 4 (2011): e1001020.

Szlezak, N. A., B. R. Bloom, D. T. Jamison, G. T Keusch, C. M. Michaud, S. Moon., and W. C. Clark. “The Global Health System: Actors, Norms, and Expectations in Transition.” PLOS Medicine 7, no. 1 (2010): e1000183.

The Global Fund. “CCM Newsletter 5”. Accessed May 6 2013. http://www.theglobalfund.org/documents/ccm/ CCM_05_Newsletter_en/.

World Bank. Word Development Report 1993: Investing in Health. Washington, DC/Oxford: World Bank/ Oxford University Press, 1993.

World Health Organization (WHO). Closing the Health Equity Gap: Policy Options and Opportunities for Action. Geneva, 2013.

WHO Maximizing Positive Synergies Collaborative Group. “An Assessment of Interactions Between Global Health Initiatives and Country Health Systems.” Lancet 373, no. 9681 (2009): 2137–2169.

York, J. “Economic Crisis hits Health Aid that helped Millions as Donors cut Back”. Globe and Mail. 2011. http://www.theglobeandmail.com/news/world/economic-crisis-hits-health-aid-that-has-helped-millions-as- donors-cut-back/article554602/.

1614 A. Ruckert and R. Labonté

Copyright of Third World Quarterly is the property of Routledge and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.