No One Size Fits All: Sharing Lessons Learned in the Governance of Health PPPs
Public-Private Partnerships (PPPs) create opportunities and produce results that are possible only when government, industry, and other sectors act together. Around the world in health promotion and health care, PPPs serve communities and patients by pooling together resources, know-how, and ideas while collectively sharing risks, responsibilities, and decision-making. However, while PPPs can be effective mechanisms for leveraging the various strengths and contributions of sectors for a shared goal, not all PPPs in global health have experienced success.
Laudable goals and the engagement of well-meaning and relevant stakeholders are not enough—often success relies on the structures, policies, and practices that govern the partnership. These governance mechanisms dictate the scope of the partnership, each party’s contribution, and the board and operational structures. But more than defining parameters, effective governance mechanisms can enhance legitimacy and ownership, and manage both real and perceived conflicts of interest (COIs). Tools for assessing transparency and accountability, and monitoring performance can help improve the effectiveness of PPPs and guide the design and decision-making of their governance.
Unfortunately there is no standard template for PPP governance mechanisms in global health. This is partly because of the significant variation across global health partnerships in size (including the number of partners engaged, resources allocated, geographic focus, and scope of the goals); focus area (spanning product development, service delivery, and behavior change); level of formality; and intended outcomes. Given both the importance of governance for PPP effectiveness and the lack of a one-size-fits-all model for its design, sharing lessons learned from both successes and failures is valuable for developing best practices and hopefully improving the success of global health PPPs going forward.
To facilitate the sharing of lessons learned and advance the discussion on PPP governance, the Forum on Public-Private Partnerships for Global Health and Safety (PPP Forum) of the U.S. National Academies of Sciences, Engineering, and Medicine convened a one-day workshop in Washington, DC, that brought together more than 100 participants from academia, government, industry, philanthropy, and non-profit organizations with experience and expertise in global health PPPs and their governance.  This post captures some of the lessons that were shared as well as practical considerations and tools for designing and assessing global health PPPs.
Enhancing Legitimacy and Ownership
One workshop speaker with experience working across sectors noted that the term PPP itself describes a clash of cultures. Government, industry, and the numerous other stakeholders that participate bring varying strengths and resources, but they also carry their own organizational cultures, regulations, and expectations. Additionally, as a number of speakers acknowledged, there are often asymmetries in their resources and influence. These differences are not necessarily problematic. A former government official who has overseen numerous health PPPs in his country reflected that the most effective partnerships have a diversity in partners and the contributions they bring.
The governance mechanism can acknowledge the diversity, establishing a legitimacy for each partner’s participation. Contributed resources range from financial to technical to political and, as several participants noted, acknowledging them in governance documents defines partners’ roles based on their unique contributions. Additionally, the governance mechanism establishes a common set of rules and regulations. It can balance the power structure by regulating who makes decisions and how and when the decisions are made.
A related theme during the workshop discussions was creating ownership and buy-in from all partners through the development of the PPP governance structure. Several speakers who have been involved in developing and managing health PPPs observed that ownership and buy-in has come when common objectives as well as the roles and responsibilities of each partner were clearly defined. One speaker shared that being proactive in identifying partners with discreet and unique contributions has aided her government agency in this process—everyone understands why they have been brought to the table and what they can contribute. Speakers shared a number of positive outcomes that have resulted from the process of developing common objectives and defining individual roles and responsibilities: 1) articulating each partner’s motivation for engagement; 2) balancing partners’ interests; 3) developing an approach that respects all represented viewpoints; and 4) managing expectations of each partner.
Issues related to ownership and buy-in often carry over into structuring and managing PPP governing boards. One speaker observed that PPP boards tend to struggle in three ways: members represent their organizational interests with limited accountability for the welfare of the partnership; the composition often is too large to make substantial decisions; and the delegation of responsibilities to management is unclear. A number of speakers emphasized the need to clarify the reasons and expectations for board membership and to be transparent about who is included and why. The diversity of partners and, at times, their participation at different levels of the governance structure necessitate active awareness raising on the partnership progress. Several strategies for managing PPP boards and partner relationships were shared:
· Establish communication processes
· Build a common language
· Communicate frequently, and
· Built in time and resources to solicit feedback.
Serving Public Interest and Managing Conflicts of Interest
PPPs should always serve a public interest objective; however, by design, PPPs raise concerns about conflicts of interest (COIs) when they marry private sector interests with public interest. This issue is particularly alarming for PPPs that create market opportunities for industry partners. Several workshop participants representing public interest organizations stated that their organizations are interested in engaging in PPPs that create a commercial market for an industry partner while at the same time provide access to needed products and services at an affordable price for key populations. One pointed out that these scenarios can offer creative solutions to tricky and so far unsolvable problems. Several participants emphasized that creating a new market itself sometimes helps to accomplish the social goals of a PPP. Creating a market, as one workshop participant said, is a question of balancing interests for social good rather than of avoiding industry engagement.
While support for market-based PPPs surfaced during the discussion, it was stressed that any partnership in which public interest organizations engage must advance a public interest objective—both to align with their organization mission and to comply with legal and regulatory requirements. A workshop speaker representing a foundation that invests in global health shared that the foundation must cautiously evaluates if the charitable purpose of a PPP outweighs the commercial one. One government representative noted that in addition to ensuring the PPP serves a public interest goal, the agency must do due diligence to ensure the partnership does not create an unfair competitive advantage for an industry partner. A multilateral organization represented at the workshop has a transparent framework for evaluating these scenarios that allows other parties to participate and mitigates potential issues with bias in the selection of partners.
Beyond considerations for balancing public and commercial interests, workshop participants discussed how they manage of conflicts of interest when evaluating the inclusion of specific partners. The point was brought up that the discovery of a potential COI does not necessarily prevent an organization’s or an individual’s inclusion in a partnership. In fact, conflicted individuals or organizations often bring relevant expertise that benefits the PPP. Excluding all stakeholders with the potential for COIs can dilute or impede the partnership’s ability to effectively meet its goal. Rather, several speakers shared that their organizations approach COI by weighing risks against the potential to achieve impact and focusing on transparency and balance among those who are represented. Many workshop participants agreed that, in general, conflicts are acceptable and manageable if declared transparently. Two strategies for managing COIs were suggested:
· Conflicted partners abstaining from voting when appropriate
· Managing COIs through firewalls in the governance structure.
Transparency and Accountability
At the workshop (and consistent with the published literature), transparency and accountability were two of the most commonly discussed dimensions of governance. Both were acknowledged as tools for enhancing legitimacy and ownership as well as managing both real and perceived COIs. At first pass, the highest levels of transparency and accountability may be perceived as indicators of good governance, but participants noted that high levels may not always be desirable.
Michael R. Reich from the Harvard T.H. Chan School of Public Health introduced a simplified matrix for assessing and designing the governance of global health PPPs based on transparency and accountability. Developed for the workshop, Reich’s simplified matrix provides a high-level analytical and planning tool applicable across types of PPPs in global health. To illuminate the complexity of determining the right levels of transparency and accountability, Reich noted that, in a PPP, certain decisions are made based on sensitive information, introducing questions of what information should be available and to which groups. Serious discussions on sensitive information can be impeded if representatives from all groups are present. Reich emphasized that the objectives of the simplified matrix are to improve conceptual clarity and help identify concrete options for action in planning, assessing, and adjusting PPP governance. It enables discussion and reflection on the desired and appropriate levels of transparency and accountability based on the specific nature of a PPP. The matrix and the corresponding paper are available here: http://www.nationalacademies.org/hmd/~/media/Files/Activity%20Files/Global/PublicPrivatePartnerships/papers/October-2017.pdf.
Workshop participants identified several ways in which monitoring and evaluation can improve the governance and effectiveness of global health PPPs: 1) establishing evaluation metrics reveals what different partners value and how they define success; 2) continuous monitoring and evaluation allows partners and the board to evaluate the PPP’s progress on its state goal and make course corrections as needed; and 3) transparency and sharing monitoring and evaluation data can inform the global health community more broadly and improve future initiatives. Providing an evaluation example, Peter Rockers and Veronika Wirtz from Boston University presented a framework to measure access-to-medicines programs. The framework development was guided by key principles: independence from industry, methodological rigor, and transparency to the public. They shared that during framework development, several tensions (e.g., public versus confidential reporting of data) occurred that provided opportunities to clarify the perspectives of different partners and strengthen the framework. More information on the measurement framework is available here: http://sites.bu.edu/evaluatingaccess-accessaccelerated/access-observatory/.
This post is a high level snapshot of the issues presented and discussed at the workshop as well as practical lessons and tools that were shared. A comprehensive proceedings of the workshop has been published by the National Academies Press and is available as a free PDF resource: https://doi.org/10.17226/25069. More information on the PPP Forum and its upcoming activities can found at: www.nas.edu/PPPForum.
 The workshop included invited presentations and panel discussions to share challenges and lessons learned. This article summarizes some of the key lessons captured from the workshop. These statements are not to be construed as endorsements by the U.S. Academies or the PPP Forum, as they acted only as conveners of the workshop.