Global Public-Private Health Partnerships: lessons learned from ten years of experience and evaluation

Abstract

Global Health Partnerships (GHPs) have contributed significantly to improved global health outcomes as well as the manner in which global health is governed. Yet in a context of an increasingly complex global health landscape, resource scarcity and a shift from disease-specific to systems strengthening approaches, it is important to continually enhance and apply our understanding of how to improve GHP performance. The authors reviewed and synthesised findings from eight independent evaluations of GHPs as well as research projects conducted by the authors over the past several years, the most recent of which involved semi-structured discussions with 20 ‘partnership pioneers’. This paper presents the major drivers of the GHP trend, briefly reviews the significant contributions of GHPs to global health and sets out common findings from evaluations of these global health governance instruments. The paper answers the question of how to improve GHP performance with reference to a series of lessons emerging from the past ten years of experience. These lessons cover the following areas:

• •Value-added and niche orientation
• •Adequate resourcing of secretariats
• •Management practices
• •Governance practices
• •Ensuring divergent interests are met
• •Systems strengthening
• •Continuous self-improvement.

These and other critical reflections inform the ‘what’s next’ agenda for GHP development.

INTRODUCTION

Over the past decade, Global Health Partnerships (GHPs) have emerged as key actors in the global health architecture. GHPs now have considerable leverage on health policy and are increasingly effective in delivering results against ambitious targets. During this period, much has been learned through experience and rigorous analysis of what accounts for success and how to strengthen partnership performance to improve population health. Given the continued appetite for networked approaches to solving global health problems, and in a context of an increasingly complex global health landscape¹, resource scarcity² and a shift from disease-specific to systems strengthening approaches³, it is important to leverage our understanding of how to improve GHP performance.

Based on expert interviews, a synthesis of independent GHP evaluations and a number of research projects, this paper draws seven lessons to inform the future course of GHP development. We begin by presenting the major drivers of the GHP trend, briefly review their significant contributions to global health and set out common findings emerging from evaluations. The paper concludes with lessons for GHPs including the perspectives of key ‘partnership pioneers’ on these issues. The paper aims to promote debate on improving better GHP performance in order to ultimately attract continued international support for partnership approaches and maximise GHP impact on global public health outcomes.

METHODS

The material for this analysis derives from a number of sources. First, from a review and synthesis of eight independent evaluations of GHPs that are in the public domain (Table 1). Second, from experience the authors have gained as advisors to GHPs or from their participation in GHP evaluations. Third, from a number of research projects conducted by the authors over the past several years, most recent of which involved semi-structured discussions with 20 ‘partnership pioneers’ - purposely selected experts who have founded or led major partnerships or served on their Boards.

Table 1.

Eight independent evaluations of GHPs

Roll Back Malaria Partnership (RBM), 2004–2008 (August 2009)

Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) 2002–2007 (April 2009)

International AIDS Vaccine Initiative (IAVI), 2003–2007 (February 2009)

Global Alliance Vaccine Initiative (GAVI Alliance), 2000–2005 (October 2008)

International Partnership for Microbicides (IPM) (June 2008)

The StopTB Partnership (StopTB), 2001–2006 (April 2008)

Medicines for Malaria Venture (MMV) (May 2005)

Global Alliance for the Elimination of Leprosy (June 2003)

Given the limited number of available external evaluations of major GHPs and the subjective nature of interviews, the authors recognise that the representativeness and generalisability of this paper’s conclusions may be limited. Further, the bias inherent in analysing a pool of GHPs that have chosen to be independently evaluated must be acknowledged. Arguably, this selective group represents leading, well-funded partnerships that are pathfinders in terms of self-critique and commitment to self-improvement.

THE RISE OF GLOBAL HEALTH PARTNERSHIPS

The emergence of GHPs has been discussed extensively in the literature4., 5., 6. (Table 2). The most influential factors include a recognition of the growing scale and complexity of global challenges, disillusionment with the structures in place to respond to such challenges, the need to accelerate the development, production and distribution of products to meet the health needs of the poor, visionary leadership, and the availability of unprecedented resources, largely precipitated by the Bill and Melinda Gates Foundation.

Table 2.

Unit of analysis: GHPs

While the ‘Global Health Partnership’ classification covers a diversity of arrangements, and often inconsistently, for the sake of this paper we cite Buse and Harmer18 who describe “relatively institutionalized initiatives, established to address global health problems, in which public and private-for-profit sector organizations have a voice in collective decision-making.” They conclude that it is the GHPs’ innovative approach to shared decision-making among multisectoral partners that distinguishes the GHP from other global health initiatives. The majority of GHPs fall into two main groups: product development partnerships and product access partnerships. A small handful of GHPs constitute two additional groups: global coordination and financing mechanisms4.

Recalling the experience of the Global Alliance for Improved Nutrition (GAIN), Rolf Carriere, founding Executive Director, remarks that “it needed to be understood that no single sector was capable of single-handedly doing what was going to be needed [in reference to the global scale of under-nutrition and the emergence of GAIN]”⁷. As they transcend national boundaries, global health challenges compel global collective action and complementarities of players with different expertise and resources to address determinants of ill-health. The unprecedented response to global health in recent years has resulted in what has been termed ‘hyper-collective action’ where the proliferation in number and heterogeneity of actors and fragmentation of collective activity is further remaking the playing field⁸. The change in terminology from ‘international health’ to ‘global health’⁹ reflects this process of the globalisation of public health, with GHPs emblematic of both that shift and a complex adaptive systems response10., 11..

Concerns about the effectiveness of the UN, driven by the UN’s perceived failure to ensure universal access to global public goods, evidence of overlapping mandates and interagency competition, and lack of confidence in the likelihood of major reform over the short- to medium-term fuelled the establishment of many partnerships12., 13.. International political and economic crises during the 1980s also roused a reassessment of reliance on the public sector. National governments increasingly began to privatise their public health sectors and partner with the private sector to provide goods and services¹⁴. It has been argued that perceptions, ideas and discourse were as important as objective reality of material power and strategic interests in the establishment of such partnerships¹⁵.

To ensure the development of life-saving technologies and their wide-scale distribution in poor countries, innovators began to explore new ways to incentivise the engagement of pharmaceutical companies given the costs, risks and low returns for research and development (R&D) on diseases that predominantly afflict the poor. This led to new product development partnerships¹. The trend towards global public-private partnerships was likely also influenced by the change in public attitudes and the growing response of the private sector to demands for corporate responsibility¹².

Visionary leadership within public and private organisations played a major, but little acknowledged, role in bringing partnerships to fruition. ‘Partnership pioneers’ possessed the unique leadership skills to convene organisations that had never before worked together and whose relationships had often been marked by disregard and distrust. The value of this talent is conveyed by Bill Foege of the Carter Center: “Leadership today is invested in the person who can put together an effective coalition. The world is so complicated no one can do anything alone anymore”¹⁶.

One of the greatest contributions to the establishment and remarkable growth of GHPs has been the generous financing provided by a number of foundations¹⁷ including the Bill and Melinda Gates and Rockefeller Foundations. Gates challenged the global health community to ‘think big’ and committed his new foundation to underwrite risky but potentially game-changing ventures. One analysis found that five of the top 11 recipients of total grants awarded by the Gates Foundation’s global health programme during 1998–2007 were GHPs: The GAVI Alliance, Global Fund to Fight AIDS, TB and Malaria (GFATM), Medicines for Malaria Venture (MMV), International AIDS Vaccine Initiative (IAVI) and Global Alliance for TB Drug Development, respectively¹⁸.

COMMON CHALLENGES IN A CHANGING CONTEXT

While GHPs have made significant contributions to global health, national systems and individual health outcomes (Table 3), many have confronted common challenges. The tension between the perceived urgent need for results from these collaborative working arrangements and adequate commitment to and investment in capacity of governance mechanisms to effectively manage these complex structures has limited the potential of many GHPs. Further, the remarkable proliferation of GHPs has resulted in duplication of mandates and activities, both between GHPs and with other entities, including GHPs’ own partners¹⁹. There remain legitimate concerns over the high transaction costs for partners and countries associated with the GHP approach, the potential for conflicts of interest to influence policy and programmatic decisions and a lack of firm evidence of the circumstances under which the GHP approach is preferable to more traditional models13., 20., 21..

Table 3.

GHPs: Transforming the global health landscape

GHPs have delivered remarkable results. They have improved the health of millions of people and made significant contributions to shoring up and shaping the global response to neglected diseases and increasingly to health system strengthening. GHPs are commonly lauded for the following achievements:

• Creating novel institutional spaces for more inclusive global health governance through innovative shared decision-making, risk sharing, knowledge and resource pooling

• Forging consensus on policy, strategy, programmatic responses and international norms and standards—including norms to which inter-governmental organisations increasingly align

• Positioning health, and specific health issues, at the core of national and global development agendas

• Increasing the visibility of and mobilising unprecedented resources -including demand-driven donor support - for neglected health issues through powerful advocacy and communications campaigns and innovative financing mechanisms

• Expanding availability of, and access to, free or reduced cost, quality-assured medicines and vaccines, particularly for neglected diseases, in low- and middle-income countries through the mobilisation of R&D, large scale funding, improved distribution networks and revisions to international trade and intellectual property regulations

• Strengthening health systems and national health policy processes, although not uniformly or sufficiently systematically

• Transforming the way many international health organisations fulfil their mandates, particularly through pressure to improve transparency and accountability and to minimise duplication of activities

In an effort to systematically understand the common problems facing GHPs, findings from independent evaluations concerning role, structure and operations were compared (Table 4). Checked boxes in the table indicate the presence of relevant findings in the respective evaluation (e.g. five evaluations found roles and responsibilities of partners to be poorly defined). Findings specific to a particular niche in the global health response (e.g. vaccine markets) are not included. A synthesis of the findings coupled with additional sources reveal seven lessons to improve the efficiency, effectiveness and relevance of GHPs as outlined in the following section.

Table 4.

Select findings and recommendations from independent GHP evaluations

Major Findings	RBM 20	GFATM21	IAVI22	GAVI23	StopTB24	MMV25	GAEL26	IPM27	TOTAL
Partnership strategy, vision and goals
Need to identify and promote added value of partnership, accounting for evolving landscape	✓		✓	✓	✓		✓		5
Governance
Lack of sufficient governance mechanism to ensure inclusive and joint decision making						✓	✓	✓	3
Board does not engage in the appropriate level of strategic, long term decision making	✓	✓							2
Board members are unable to adequately represent their respective constituencies				✓	✓				2
Stakeholders and partnership priorities are not adequately represented by Board composition			✓		✓	✓		✓	4
Poor transparency of governance and decision making processes			✓	✓			✓	✓	4
Poor performance transparency					✓		✓	✓	3
Organisational effectiveness
Weak strategic planning and/or lack of an overarching partnership strategy	✓	✓	✓	✓	✓		✓	✓	7
Poorly defined roles and responsibilities of partners	✓	✓		✓		✓	✓		5
Weak partnership performance evaluation framework and accountability mechanisms	✓	✓	✓	✓	✓		✓		6
Secretariat structure/staffing does not support partnership effectiveness		✓	✓		✓	✓		✓	4
Attempts to address too many issue areas have diluted impact of the partnership vanguard			✓		✓				2
Policies and funding allocations not based on strategic priorities				✓					1
Inadequate identification and support of cost-effective interventions		✓		✓					2
Inadequate investment of effort in data collection and analysis to drive consensus on opportunities				✓	✓				2
Collaboration between colleagues undermined by poor personal relations and subsequent lack of trust							✓		1
Global high level advocacy efforts need strengthening	✓		✓					✓	3
Ethics
Lack of mechanisms to manage conflict of interest	✓								1
Inadequate attention to promoting equitable access		✓	✓					✓	3
Country support
Mechanisms to promote country ownership are weak		✓		✓					2
Inadequate support to building country capacity	✓	✓		✓					3
Country activities are not sufficiently tailored to country performance, capacity and needs		✓		✓			✓		3
Inadequate support to strengthening information systems and monitoring capacity in country		✓		✓					2
Sustainability
Poor mechanisms to ensure long term financial sustainability of programmes		✓		✓		✓		✓	4
Inadequate risk management		✓	✓					✓	3

LESSONS FOR GLOBAL HEALTH PARTNERSHIP PRACTICE

Identify and play to the partnership’s comparative advantage

“What distinguishes successful from unsuccessful partnerships is common vision, shared commitment, and partners that bring together complementary skills and resources to attack a problem. They do it in a way that places it at a comparative advantage.”

Jeffrey Sturchio, President and CEO of the Global Health Council; Former President of the Merck Company Foundation³⁰.

In an increasingly competitive resource environment, a GHP must be able to convincingly demonstrate that its joint work uniquely positions it to address an otherwise unfilled, but critical, gap in the global health architecture. Partnerships must define their value proposition not only by ambitious goals, but by their distinctive contribution and comparative advantage in reaching those goals. To achieve this, partnerships must define and adhere to a unifying partnership strategy towards a shared vision. As William Foege states, “an effective coalition is able to define what the last mile looks like¹⁶.” Such a strategy helps to avoid the tendency for partnerships to encroach on the roles of partners and other institutions.

Such a niche-orientation was, however, strikingly absent in the partnership strategies reviewed by independent evaluators. For example, the evaluation of Roll Back Malaria (RBM) found that the partnership lacked a clear and common vision for its future operations. The changing tuberculosis landscape led StopTB’s evaluation to suggest that the partnership clearly define its role “to distinguish itself from the increasing number of organizations and partnerships involved in TB control and research.” To ensure and maintain their relevance, GHPs should delineate a unified articulation of the role they play, or strive to, in the global architecture with systematic monitoring of the added-value of their collaborative approach.

Adequately resource partnership secretariats

The size of a partnership’s secretariat has been found to be a critical factor in determining its success. Secretariats are tasked to coordinate partners through open and efficient means of communication of positions and actions, a task which is highly people-intensive³¹. Five of eight evaluations reviewed argued that the Secretariat under assessment was ill-suited in size and structure to support partnership effectiveness. A 2007 Management Review of the Global Fund found the Secretariat too small to adequately manage its growing portfolio, despite considerable Secretariat growth³². Evaluators found that StopTB’s lean staffing model came at the cost of operational effectiveness²⁶. Moreover, small secretariats, it has been argued, promote the tendency to advocate ‘one size fits all’ attitudes in country operations due to the lack of capacity to respond to local contexts³³.

Large secretariats may not be feasible or desirable, yet secretariat size and structure should be a deliberate strategic consideration of any GHP bearing in mind the implications of under-resourcing for achieving the value-added of working in collaboration and the goals that the partnership sets for itself.

Practice good management

The creation of a partnership is not without substantial costs. Garnering commitment and consensus from new or potential partners and maintaining a flexible, loose-knit structure requires some degree of ambiguity regarding roles and responsibilities, rendering strategic management, oversight and accountability more of an art than a science. Nearly all of the evaluations reviewed for this paper found deficiencies in these areas. For the GAVI Alliance, partnership effectiveness was derived from a shared sense of purpose, trust and commitment rather than a clearly defined structure²⁵. However, as GHPs mature, and their portfolios and partnerships grow, professional management structures and strategies become increasingly critical to optimise partnership performance, monitoring and accountability, as the evaluations of the GAVI Alliance, the Global Fund and StopTB found.

Lack of SMART (Specific, Measureable, Attainable, Relevant, Time-bound) objectives, performance management and continuous internal assessment was found to undermine the work of the majority of partnerships reviewed. For example, the evaluation of StopTB found that its ‘failures’ were for the most part due to insufficiently effective performance management of the various Partnership bodies. Further, the evaluation found that the specific objectives of a number of StopTB’s advocacy activities had not been defined while other activities were not associated with clear metrics or targets.

Efforts to formalise partnership agreements and organisational structures should be intensified and defined through strategic and operational (or business) plans. These must clearly define roles and responsibilities of all major partners, set measurable objectives with indicators and targets for monitoring progress against these objectives, including partner satisfaction and commitment, and establish an evaluation process.

Practice good governance

The health impact of GHPs continues to be undermined by weaknesses in governance. In particular, representation, transparency and accountability represent evolving challenges.

Representation

Evaluations of IAVI, IPM, MMV and StopTB found that Board compositions inadequately represented relevant stakeholders. Processes to select board members should be transparent, fair and inclusive, with explicit selection criteria based on an agreed balance of diversity and expertise. Further, two evaluations found that while certain stakeholders may be technically represented on the Board, inadequate mechanisms exist to enable members to properly represent their constituencies, particularly those from developing countries. A standard process for communication and input between board members and constituencies needs to be put in place and should include performance evaluation of board members by their constituencies to enhance accountability.

Transparency

Transparency within partnerships combats duplication, highlights operational gaps and facilitates input and feedback between partners on how to maximise impact. Further, transparency is increasingly vital in a resource-competitive environment to attract donor support. While several GHPs already make considerable amounts of information available on their websites, five of eight evaluations found inadequate transparency either in decision-making or performance reporting. As a matter of principle, in order to ensure public accountability and internal efficiency, all GHPs should publish key governance, financial, operational, and performance documents and decisions on the internet.

Accountability

Accountability of GHP partners to the partnership is dependent upon clear specification of objectives and agreement on roles and responsibilities required to achieve those objectives⁶. A formal system of accountability of partners—including work plans, deadlines, deliverables, and sanctions for non-performance—is increasingly important as GHPs move from loose arrangements into durable, strategic partnerships. Transparency, particularly of performance reporting, can be employed to influence partners in delivering on their commitments.

Formalisation of GHP governance structures must, however, be balanced with the need to retain the flexibility to respond to challenges and opportunities. Evaluators argued that the GAVI Alliance’s governance structure suffered from poorly defined roles and responsibilities and poor accountability, yet its flexible structure allowed it to sufficiently manage the growing size and complexity of its programmes through rapid decision-making, innovation, and self-assessment.

Acknowledge and respect partners’ divergent interests

A significant barrier to successful collaboration is a lack of understanding or appreciation of the pressures and incentives faced by different partners. Successful alliances must be mutually beneficial. Chris Elias of PATH observes that “it is unproductive when one constituency acts like the other partner doesn’t have a difference in interest³⁴.” Attracting and maintaining partners may not be possible without understanding differences in organisational culture and the values and interests that motivate partners³⁵. Engaging the private sector has been a particular challenge for GHPs. Lack of understanding and inappropriate expectations among partners were found, for example, to have limited the involvement of vaccine manufacturers within the GAVI Alliance.

Private actors often engage in GHPs as a corporate social responsibility endeavor and may view them as separate from their core activities. These partnerships can, however, be beneficial for private sector participants through, for example, expanding networking opportunities, exposure to knowledge and best practices, a more satisfied workforce and access to new markets without compromising the objectives of the GHP. Ensuring long-term and meaningful partnership with a private sector partner requires demonstrating a return on investment and appealing to the profit-oriented values of the private sector¹⁹.

Ensure operations impact positively on national and local systems

While GHPs have made significant contributions to improving health outcomes by addressing major burdens of disease, less clear is the impact they have had on the health systems of the countries where they operate. The disruptive impact of GHPs at country level has been discussed extensively in the literature20., 36., 39. and often manifested as: high transaction costs on recipient administrations; weakened country ownership of national strategies; and distortion of national priorities, human resource allocations and service delivery structures. While validating that these unfavourable outcomes can be the result of GHP influence, recent studies illustrate that the interaction between GHPs and health systems is highly variable and that, in many cases, GHPs have contributed to stronger health systems36., 40.. With growing recognition that weak health systems are a central barrier to progress on health goals, it has become critical for GHPs to better understand their interaction with health systems, and how this interaction affects their ability to improve health outcomes more effectively and efficiently.

The evaluation of the Global Fund, for instance, found that its “contributions to health systems strengthening were often limited by poorly harmonized and aligned reporting requirements, activities, and systems.” Further, the Global Fund and the GAVI Alliance evaluations also found insufficient prioritisation of the most cost-effective interventions.

GHPs need to increasingly differentiate their approaches in specific countries based on self-identified country priorities, epidemiological profiles and the assessment of a country’s capacity to execute its planned disease control programmes. GHPs, along with a diverse set of bodies in the global health arena, must also seek a more coordinated approach and systematic investment to strengthen country health information systems as a basis for monitoring progress, enabling performance-based funding mechanisms and designing evidence-informed responses. Further, while GHPs have been highly successful in mobilising resources, more attention needs to be focused on building capacity and ownership and increasing longer-term financing commitments within countries. The increasing support of the Global Fund, the GAVI Alliance, StopTB, RBM, and other GHPs to strengthen health systems demonstrate their acknowledgement of the need to accompany scale-up of disease-specific programmes with measures to achieve broader system strengthening goals.

Strive for continuous improvement

GHPs have been in the vanguard in many respects, not least in their embrace of self-critique and self-improvement, evidenced in major investments in independent evaluations and subsequent efforts to act on evaluation recommendations, particularly the eight reviewed here (Table 1). Nonetheless, a number of evaluations noted that partnerships will need to monitor the evolving landscape more rigorously than in the past to react quickly to emerging challenges and opportunities and need to put mechanisms in place to do so more systematically. With all of the moving parts inherent in the structure and functions of a GHP, Chris Elias, of PATH suggests that “the focus needs to be on the process of how you develop a partnership rather than saying here is a template and this is how you should do it³⁴.” The GHP should regard itself more as a learning process rather than an organisational structure. This suggests the need to must continually invest in identifying and agreeing upon the biggest opportunities for partnership impact and the actions required to realise these opportunities.

GHPs continue to make important adjustments to the way they work. Each have, in their relatively short years of existence, confronted and overcome considerable challenges. Such richness of practical experience and innovation in addressing problems that are often common to many GHPs needs to be shared more widely.

DISCUSSION: THE ‘WHAT’S NEXT’ AGENDA

The GHP evaluations reviewed reveal a remarkably common set of challenges. The evaluations also offer some common recommendations to strengthen the manner in which GHPs operate which we have attempted to synthesise above. The relatively small number of independent GHP evaluations publicly available, however, reflects the generally inadequate commitment of global health programmes, including partnerships, to evaluation. The lack of investment in evaluation and links to decision making for enhanced efficiency and effectiveness has recently been accused of “damaging the entire global health movement⁴¹”. GHP staff and board members are encouraged to reflect critically on the lessons emerging from assessments of individual GHPs as well as on the broader set of learnings and consider how they can use them to improve the performance of the GHPs in which they are involved.

The experience of the past ten years also invites the global community to step back and reflect upon the overall direction of travel and the ‘what’s next’ agenda for GHPs. In our view, two items for the agenda stand out: comparative GHP assessment; and the burden of disease targeted by GHPs.

The concept of a comparative partnership performance metric began to attract interest as early as 2004⁴² and at least two GHP performance metrics have been developed and published14., 43.. A comparative metric, while challenging to construct, could serve a number of purposes: reduce the burden of donor monitoring and evaluation; improve understanding about GHP performance and inform the GHP performance management process; communicate partnership successes through a common language of performance measurement; bring clarity, structure, best practice, and collective learning to GHPs and donors alike; and help secure longer-term funding from donors by enabling donors to assess and track partnership performance, thereby assisting them in justifying their support.

We therefore propose the elaboration of a performance metric allowing comparison across all GHPs. This metric moves beyond analysis of ‘operational indicators’ of GHP performance, an area of research where many individual GHPs have made great strides, and ventures forth into analysis of ‘core indicators’ of performance that inform stakeholders about how GHPs are delivering on their overall goals. Core indicators might be grouped around four dimensions of GHP performance:

• •Public health (e.g. the public health importance of the issue addressed; implementation strategies; health impact)
• •Partnership logic (e.g. demonstrating added-value)
• •Delivery systems (e.g. commitment to country ownership, alignment, and harmonisation)
• •Governance (e.g. representativeness, transparency and accountability).

In reflecting on the public health importance of GHPs, it is worth noting that the GHPs that we have focused on, as well as the vast majority of other global health initiatives, aim to address the considerable burden of communicable, and typically neglected, diseases in low- and middle-income countries. As we argue above, this has represented one of the triumphs of global health efforts over the past decade. Nonetheless, with non-communicable diseases now accounting for more than half of the burden of disease in low- and middle-income countries, and growing, attention is turning to tackling non-communicable diseases through partnerships.

While a number of partnerships have emerged to address non-communicable disease in the global South, including ones such as GAIN and the ‘Live.Learn.Laugh.Partnership between the FDI World Dental Federation and Unilever Oral Care’ (the subject of this Supplement)⁴⁴, public-private collaboration has been much less pronounced. There are many indications that industry is showing an interest in partnership in the area of under- and mal-nutrition, going so far as to claim that “Only through new and innovative public–private sector partnerships can we truly make a difference⁴⁵.” While there are many dissenting voices⁴⁶, there are indications that we will see a growth in partnerships in this area. We would urge the architects of these partnerships to draw on the lessons that have emerged from a decade of experience with communicable disease partnerships.

CONCLUSIONS

Given the major contributions afforded by the GHP model, we can expect that GHPs will remain a major facet in the global health architecture for years to come. Effective GHPs deliver not only health outcomes but are also, in some way, transformative of partners, imbuing the public sector with business skills and encouraging business to operate with social values.

Experience to date, however, also suggests variable performance across different aspects of partnerships. Differential performance carries three linked implications. First, the need for sustained critical reflection and independent evaluation so as to ensure optimal results given the level of resources that collaboration demands. Second, the benefit of opening up spaces for public debate so that the findings from evaluation can be frankly discussed . Third, applying lessons more widely across and within partnerships.

As we move from an era of abundance to an era of scarcity, it is increasingly important to ensure that the models applied to solve the challenges of global health are evidence-informed. The first generation of global health partnerships have confronted novel problems in innovative ways, and it is critical that lessons learned over the past ten years inform the solutions of the next generation.

ACKNOWLEDGEMENTS

This paper was originally presented at a symposium on the Live.Learn.Laugh Partnership of the FDI World Dental Federation and Unilever in Singapore, 2 September 2009. It builds on an analysis undertaken with Andrew Harmer and incorporates material from interviews which he conducted. KB is indebted for his contributions and insights. The views presented in this article are solely those of the authors.

CONFLICT OF INTEREST AND SOURCES OF FUNDING

Neither Kent Buse nor Sonja Tanaka have received any funding in relation to the preparation of the paper or have a conflict in this matter.