3

Multistakeholder Perspectives on Public–Private Partnerships for Health Systems Strengthening

All sectors and stakeholders benefit when individuals and communities have access to affordable and high-quality care, markets exist for new technologies and promising interventions for health improvements are implemented effectively, the labor force is healthy and productive, and public health systems are in place to detect and respond to emerging threats. A strong health system underpins these conditions and their sustainability. With this growing recognition, both public and private stakeholders are realizing not only the opportunities for partnerships for health systems strengthening, as described in the previous chapter, but also the related incentives. Trevor Gunn from Medtronic noted that there are numerous examples of successful public–private partnerships (PPPs) developed to improve infrastructure, such as building roads, and he attributed the success, in part, to established incentives for all contributing partners. Yet, when it comes to developing PPPs for strengthening health systems, Gunn observed that such development can be incredibly challenging because the incentives are not well understood for all parties. This chapter illuminates the incentives for investing in health systems that were discussed at the workshop through descriptions of motivations and case examples.

PUBLIC-SECTOR PERSPECTIVE FROM THE CHILEAN NATIONAL HEALTH SYSTEM

Jeanette Vega from the National Health Foundation in Chile spoke about her experiences as the director of the National Health Insurance Agency (FONASA), which covers 80 percent of the Chilean population. She stated that PPPs are complex, particularly in delivering health care. Evaluating such programs involves having a system for assessing the finances and making sure the government is able to classify, measure, and allocate risk appropriately to each partner.

From Vega’s perspective, the most important requirement for PPPs is an established governance process, which can be extremely challenging because it requires institutional stability and effective decision making with a clear vision of the country’s needs. The other important requirement is for the host government to have a clear, predictable, and well-regulated legal framework before investing heavily in PPPs. In particular, the government must be certain about the level of profitability, compared with the specific sector average, that it is willing to pay or accept in any partnership with the private sector. For example, what are the comparative costs of operation when the government uses the private sector to deliver care compared with when the public sector provides the same care? Vega also acknowledged that the government must conduct a thorough risk assessment to identify the risks, costs, and quality tradeoffs, as well as a risk-sharing model to ensure greater value for investment.

The next step is to define clearly what the desired deliverable should be for every potential partnership. To illustrate, Vega detailed how the Chilean health system is structured. First, every citizen who works in the formal sector pays a compulsory contribution of 7 percent of their salary for health (Missoni and Solimano, 2010). Those unable to pay—informal workers with no stable work or who have income below the poverty level—are subsidized from general budget revenues to fund their health services. Through this system, every citizen in Chile is insured. Citizens can opt-out and seek private insurance if they prefer or they can be insured by the Social National Health Insurance Agency, FONASA, which is responsible for all the revenue collection, pooling, and purchasing of health services for those insured, generally the lower- and middle-income people, while high-income workers and their families are usually insured by private insurers. In practice, FONASA administers most of the country’s health resources, as it covers almost 80 percent of the population in the country. The provision of services is mixed using private and public providers in the case of Fonasa and private in the case of the private insures. In both cases there is a national compulsory health plan.

The Chilean national public health system provides a range of ser-

vices from hospitals to primary health outpatient services. There are also private providers. Currently, the government is working toward an innovative PPP by strengthening the connections of FONASA with the private providers. This partnership is the result of a necessity, as there is a shortage of hospital beds (an estimated shortage of 2,000 beds) and services in the public sector. The government also believes that an innovative PPP could be advantageous to both sectors. Through the partnership, the public sector could extend coverage to its members and the private sector could expand its business model. For example, the government has modified its pay structure to rationalize and improve the public system while purchasing access to hospital beds, outpatient care, and hospitalized care as needed from the private sector. In addition, the government is negotiating with the private sector to equalize pay across both sectors and to provide accessible health care to their citizens.

Another innovative example that has led to stronger information systems is the introduction of chronic disease care through “telemonitoring” for case management. The government, in partnership with a private company, has introduced telehealth services for chronic care of diabetic and hypertensive patients in the largest health system of the capital city Santiago that covers more than 1 million people. In brief, each primary public health care center in the area offers program enrollment to all patients seeking better control of their diabetes and hypertension. The program is financed on a per capita basis, based on a definition of care according to the level of complexity of each patient enrolled. The frequency and type of specific care activities are defined by the complexity of each case, with the goal of keeping the patient clinically compensated. At entry, each patient is monitored for 15 days, during which time the patient is classified on stage of disease. Then, each patient is provided a set of services, including biological monitoring from home and transfer of the information to a central care unit that is managed by the private partner, plus the use of SMS (short message service), telephone, and virtual communications to manage his or her symptoms and biological parameters. All of these services are provided remotely while the patient remains at home. Devices are used to monitor the patient’s blood sugar level and his or her parameters for blood pressure, and results are sent to the center. Clinical feedback is provided to the patient for education and medication adjustments. If the patient requires consultational hospitalization, he or she is referred to the public facilities of the health system, with follow-up through online communication between the private and public providers.

Interestingly, this program is provided to a community with more than 1 million people, of which 26 percent have hypertension and around 8 percent have diabetes. After 6 months of implementation, the program has provided care to a greater number of individuals and saved an aver-

age of 56 percent in the costs of providing patient care. Through these innovative PPPs, FONASA and the Chilean health system have demonstrated effective ways to improve the health care system, leading the system toward preventive health care and promoting a culture of healthy living.

The development of these successful PPPs was not without its challenges, Vega continued. An underlying tension exists among Chilean policy makers over which health care services should be provided by the public sector and which should be supported by private clinical organizations. Furthermore, Vega noted that there is often a fundamental difference in what is considered public and what is deemed private. For example, although the Canadian health system is not considered a private one, many of the services in Canada are indeed provided by private clinicians. In Chile, forming partnerships with private businesses also proved to be challenging, Vega explained. Instead of contracting with large private companies that can offer health care more efficiently, the Chilean government is supplementing the income of private physicians by allowing them to use public facilities to provide care. The availability of facilities and services within the public sector remains a challenge.

In response to Vega’s presentation Jo Boufford from the New York Academy of Medicine noted that Chile has made substantial progress in developing the governmental infrastructure, legal framework, regulatory environment, and capacity to manage the delivery of universal health care. Boufford asked Vega to discuss the process for developing the infrastructure. Vega responded by stating that, over time, there have been many lessons learned, often through failed or difficult processes. To provide context, Vega offered a historical perspective of the Chilean government. Chile was the first Latin American country that introduced socialism by democracy, and then it was run by a military dictatorship for 17 years. During this time, several initial experiments were conducted, with support from the World Bank, to create a social space to lead to a free market. With each failure, the key issues were a lack of governance and legal frameworks to manage relationships between the Chilean government and other entities. This translated into unsuccessful contracts, poor monitoring, and ineffective and untimely measures, making it challenging to respond to and/or develop solutions to resolve the issues. Vega acknowledged the more than 20 years of failure in implementing successful health information systems in Chile. The main implementation issue has been the challenges of the Chilean government to partner with the private sector. FONASA will be initiating its third attempt to develop a health care information system for the entire country, with the aim of integrating all segments of care. As part of this current process, the government is adopting proven approaches from the private sector.

More recently, Vega helped develop a partnership with the private company Oracle to redesign the national health care information system. The primary purpose for this contract with the private sector is financial, as well as to have access to two well-established, high-quality products from Oracle. One of the products is called OIPA (Oracle Insurance Policy Administration), which develops individual health care accounts that trace care and costs associated to each insured individual. The other product is OHI (Oracle Health Insurance) software. The most challenging issue was to convince FONASA’s workers, as well as the general public, why this model is going to be successful and why this contract should not be considered as privatizing. Vega explained, “Basically, we have a very clear underlying objective for us it is to introduce a system that works. For Oracle, it is to basically introduce a system that they have working right now in one country that is quite influential in the region. If we do it right, it is going to be—in addition to the margin of commercial profit—a win-win situation in terms of the outcome, which is to improve health systems. It is a very long answer to our question, but I am basically trying to say it is from failure [that the infrastructure has been developed]. That is usually the way it is.”

PRIVATE-SECTOR PERSPECTIVE FROM BECTON, DICKINSON AND COMPANY

Gary Cohen from Becton, Dickinson and Company (BD) spoke about his experience working across sectors. Cohen argued that companies that focus on unmet societal needs, and partner with governments and other stakeholders across sectors to address those needs utilizing the core competencies of the company, can identify ways to enter and grow in new markets. Cohen reflected on a quote, “The bottom of the pyramid today is the middle of the diamond in the future,” stating that over the past 15 or 20 years in many emerging countries, a growing middle class has created prosperity and enables, in theory, companies to expand their access. But, unless companies learn how to function in new markets and work with the public sector, expansion will be difficult. Cohen explained that the traditional business models of sales people carrying bags and pushing their products into the market may not be effective; rather, business models that are based on building trust and partnering to address unmet needs will be more effective ways to expand in new markets.

Although the term “public–private partnerships” is relatively new, and perhaps the definitions of such partnerships may differ, Cohen described several experiences over the past 20 years that changed his thinking on what can be accomplished when working together across sectors. To begin, he shared an experience from December 2003 when he

traveled with a delegation of approximately 100 health leaders to sub-Saharan Africa to study the HIV and AIDS pandemic. As a result of that trip, he and the top executives at BD mapped out all areas in which the company could contribute to addressing the HIV and AIDS pandemic. At the time, the primary emphasis in HIV and AIDS was on the delivery of treatments, not on health systems strengthening, laboratory testing, and other components. This mapping of unmet need resulted in BD establishing a new global health function within the company dedicated to cross-sector partnership to address HIV and AIDS and other highly prioritized health needs.

Cohen categorized PPPs from the perspective of BD into three primary categories: social investing, corporate social responsibility, and shared value creation. The first, social investing or philanthropy, is when the private partner’s role is as a hands-on, active donor of cash or in-kind product. For example, BD partnered with U.S. Fund for UNICEF in the late 1990s to eliminate maternal and neonatal tetanus (MNT). Cohen stated that BD supplied approximately 60 or 70 million safe, auto-disable immunization devices and about $10 million in funding, and between 1999 and today, MNT deaths have been reduced by more than 70 percent. During this same time period, about 6 billion immunizations have been administered safely, primarily to children, using this type of technology, helping to eliminate an entire category of disease spread from reuse of single use immunization devices.

The second category, corporate social responsibility, is when private companies use their core competencies to accomplish a social good. For example, BD partnered with the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and the Centers for Disease Control and Prevention (CDC) in developing Labs for Life, where the goal is to strengthen laboratory systems in five countries in sub-Saharan Africa and India. This work also led to another partnership with the same partners focused on strengthening phlebotomy and blood drawing practices, for safety, accuracy of diagnosis, and transport. In both of these examples, BD is using its experiences and expertise to improve the quality of care provided, with no direct commercial objective or benefit obtained.

The third category is called shared value creation, where intentionally and specifically, the partnership focuses on an unmet societal need in a manner that also provides a business opportunity. In January 2004, BD partnered with the Clinton Foundation to make CD4 monitoring widely accessible; CD4 monitoring measures the immune system of people living with HIV and AIDS, so clinicians know when to begin antiretroviral therapy. The timing of this work was right on the cusp of the scale-up of antiretroviral therapy, providing a shared value opportunity. BD offered low-access pricing and opened up opportunities to expand the market to

55 developing and emerging countries. Within a few years, CD4 testing was widely accessible. In the process of that partnership, BD trained more than 8,000 laboratory technicians on how to perform immune system monitoring, which contributed to laboratory systems strengthening.

Building on that work, in 2005 BD established a volunteer program to deploy associates to developing countries to help strengthen health systems locally; and from there, it entered into the first laboratory systems strengthening partnership with PEPFAR. This PPP, which became Labs for Life, was more broadly based, with the objective to assist laboratories through the accreditation process. At the time very few labs, particularly in sub-Saharan Africa, were at an accredited level. This BD–PEPFAR partnership was highly successful and led toward a reduction in the turnaround time for tuberculosis (TB) testing in Uganda from 3 weeks to 3 days. Indeed, 14 percent of TB treatment cases in Uganda were identified as multiple-drug resistant, and treated accordingly. In Ethiopia, this partnership facilitated the implementation of a nationally integrated specimen referral and handling system, including involving the postal service in transport. In Mozambique, the partnership supported development of a national laboratory quality system. BD was working very much in the spirit of PPPs at the national level, with the national government, CDC, and BD working together on the ground with the local governments implementing the program.

Another partnership that Cohen discussed was with the International Council of Nurses (ICN). This PPP focused on wellness centers for health workers, in response to the emigration of health workers from developing countries to developed countries, presumably due to low wages in their home countries. Intolerable working conditions and the high potential of contracting disease occupationally in the health care environment were also important indicators for this health worker emigration. In response, the ICN, BD, PEPFAR, and the Stephen Lewis Foundation entered into a partnership to establish wellness centers, safe havens where health workers and their families can go for discrete testing, counseling, and treatment. Swaziland was the first country where a wellness center was implemented, and the partnership tracked the migration of nurses after establishing the wellness center. The migrant level was brought down to zero, and the partnership provided a highly efficient, high return on investment.

In closing, Cohen imparted one final example of a shared value creation. BD recently entered into a collaboration with the World Health Organization (WHO) and Saving Lives at Birth partners to develop the BD Odon Device™, a new innovation aimed at replacing forceps and vacuum assistance for delivery of newborns during circumstances of prolonged, troublesome second-stage labor—one of the primary causes

of both maternal and newborn mortality. As of 2015, newborn mortality represented 44–45 percent of all under age 5 mortality, with nearly 2.7 million newborns dying in the first 28 days of life; not including another 2.6 million stillborn births, which were not necessarily tracked, and 289,000 women and girls dying in childbirth in 2013 and more than 10 million having severe complications. BD is leading the product development process and the WHO is conducting the clinical trials of the BD Odon Device. The International Federation of Gynecology and Obstetrics (FIGO) is expected to develop the usage guidelines and training, which it will implement through its country chapters. The Saving Lives at Birth partners, which include The Bill & Melinda Gates Foundation and the governments of Canada, Sweden, the United Kingdom, and the United States, are providing support through multiple mechanisms, such as funding for the clinical trials.

Based on the significant unmet need of high rates of maternal and newborn mortality, BD made a strategic decision to deploy its resources and capabilities to develop a broader range of innovations that can address leading causes of maternal and newborn mortality, taking advantage of the scale capabilities within a global company. BD is working on a blended finance model with the Global Health Investment Fund to develop two new point-of-care tests to address two of the leading causes of maternal mortality, preeclampsia and gestational diabetes.

These efforts are helping to establish the next generation of finance models using blended finance and risk and providing an opportunity for shared value creation, with the aim of developing sustainable business models with high access in the highest-burden countries. In distilling some common principles that led to the success of BD’s PPPs, Cohen listed establishing trust as extremely important, as well as identifying the right leaders and champions and aligning purpose and motivations.

PUBLIC-SECTOR PERSPECTIVE FROM EXPERIENCE WITH THE UK DEPARTMENT FOR INTERNATIONAL DEVELOPMENT

Simon Bland reflected on his experience at the Department for International Development (DFID) in the United Kingdom and its interface with two global funds, the Gavi Alliance (Gavi) and the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), identifying incentives that were effective in engaging partners and raising funds, as well as suggesting future directions for establishing multistakeholder partnerships.

To begin, Bland stated that regardless of whether one comes from the public or private sectors, individuals have their own experiences, prejudices and biases that must be acknowledged, understood, and broken down to build trust and to identify and agree on common values. Bland

observed that only recently has there been a stronger recognition, drive and capacity within the public sector to engage with the private sector in international development. There were perceptions of conflicts of interest, of providing unfair commercial advantage and a lack of understanding, common skills and language across public and private sectors. He believes that this mentality has changed substantially and there have been numerous successful examples of PPPs demonstrating the value and impact they can have on strengthening health care systems.

Another observation Bland made was that in the public sector, domestic politics and public opinion have had a major impact on priorities. Indeed, incentives have been developed as a result of national debates and the resulting perceptions of the issues. That said, Bland remarked that official development assistance represents an important but relatively small proportion of the overall resources available for strengthening health care systems and, in particular, for supporting the Sustainable Development Goals (SDGs). He noted in Africa alone, official development assistance in 2012 was $50 billion while domestic resources mobilization was $530 billion. Importantly, health systems are going to be funded by domestic resources through whatever financing mechanisms are available. The challenge of the future is figuring out how development assistance can be best focused in a way that is directed toward the greatest needs of the system, addressing the market failures and creating the right incentives for broader leverage, change, and improvements.

Bland pointed out that the United Kingdom was the first G7 country to reach the Monterrey Consensus commitment of 0.7 percent of gross national income (GNI), and the government is now seeking support from other countries to make the same international commitments for financing (Townsend, 2014). Bland also highlighted a challenge in the United Kingdom of maintainging public approval for development assistance globally. Historically, public opinion in the United Kingdom has been more supportive of providing financial assistance for development through local charities and projects rather than through governments and international organizations. As such, providing funds to support the delivery of global health care through large PPPs, global funds, or the international organizations does not always garner public support. Nevertheless, the House of Commons International Development Committee recently released a report stating that the United Kingdom has been an active investor in health systems globally through its bilateral programs, working with national governments to try to build those systems (House of Commons, 2014). Increasingly, though, the United Kingdom relies on the international system including the Global Fund, Gavi, and other international organizations to channel this support.

The United Kingdom recently conducted an assessment of 43 interna-

tional organizations in terms of relevance to their development priorities, their added value, cost effectiveness, and their ability to deliver results. The primary findings suggested that the single-issue-focused funds that are often supporting vertical programs perform remarkably well in terms of being a good investment. Bland stated that a comparative review of this nature introduces competition and edge into the market to drive performance and efficiency, but it fails to assess the systemic issues of how the broader international system comes together to deliver health care and that the synergies and reliance between organizations are often ignored. To be effective and address the global health care delivery systems, Bland believes the needs of health systems must be communicated more effectively to donor governments, including how the health system is defined, why it is important, how to build and strengthen it, and how investing in it yields results and why, without this, the results achieved by Gavi and the Global Fund would suffer considerably. Although the United Kingdom has supported health systems strengthening investments through both Gavi and the Global Fund, as well as bilaterally and through others, Gavi and the Global Fund investments have been a small fraction of the total resources that these funds have invested. While there have clearly been system benefits from Gavi and Global Fund investments these have not yet translated into vast improvements across health systems.

The Global Fund, Gavi, the World Bank, and the WHO agreed to try and harmonize their investments to strengthen health care systems. Together, they developed a Health Systems Funding Platform that aimed to streamline funding and collaborations with host governments to deliver the targeted program while also strengthening the health system to deliver the program. Though the concept was strong and could have been transformative, Bland stated that operationally it took more than 2 years to develop a common, shared mechanism to harmonize approaches to health systems strengthening in countries and that the scheme never progressed from the long planning process. That said, Bland has observed vast differences across developing countries with respect to the strength of their leadership and governance and, as a result, he suspects that the approach to health systems strengthening may need to be tailored for each country to assist in building its capacity, leverage resources, negotiate effectively, target priority areas, and provide technical assistance and training that can meet the national contextual needs.

Bland believes that although the Global Fund and Gavi and other similar organizations will continue to support the strengthening of global health systems, they are unlikely to expand significantly in the future. Instead, he believes there will be numerous national and subnational partnerships developed that significantly drive improvements and innovations through specific programs, contextual circumstances, and strong

leadership. There is complexity within each country and sometimes several tracks are needed at the same time, he added. For example, in Kenya, the DFID supported twin tracks. The first targeted the short-term delivery of results, where intermediaries, such as Population Services International (PSI) and other nongovernmental organizations (NGOs), as well as working directly with government, contributed. At the same time, broader efforts were undertaken to help support and strengthen the building blocks for a stronger health care system.

The perceptions of risk remain high. Concerns of corruption and illicit finance are pervasive. Yet, as Bland pointed out, recent research suggests that infrastructure investments across the globe, regardless of the level of wealth within the country, demonstrated little difference in return on investment, while the perceptions of risks of returns are significantly different. Collectively, there is a need to challenge this assumption, Bland suggested, and promote stronger private-sector investment in ways that support national development and free up public finance for the social sectors.

Ambassador John Lange from the United Nations Foundation noted that Bland highlighted the vertical programs that have been successful, but suggested that the future is in the national and subnational levels for partnerships. Indeed, one of the SDGs is universal health coverage. Lange remarked that currently there is not one entity that provides financing facilities for improving health care systems globally and wondered how the multilateral, global approach to strengthening health systems through PPPs will be operationalized. In response, Bland stated that it is difficult to predict and wondered if a global fund for health is needed or if an institution should be established to deliver on health systems strengthening. Bland also pointed out that global funds for areas such as education and agriculture are being promoted by some. But more funds could mean more fragmentation, when a more coherent approach is required. While the Global Fund and Gavi are remarkable institutions, they are primarily financing institutions and neither has a country-level presence and, as such, both work through intermediaries. That said, Bland commented that further change is needed to create incentives to drive global impact on building health systems at the national and subnational levels.

In response to Bland’s comments, Gunn noted that successful capacity building highlights the importance of and necessity for education and training. Gunn has observed that the PPPs dedicated to improving education and providing training have had the least resistance from governments and provide one of the highest degrees of societal value regardless of who provided the original training. Cohen agreed with Gunn that education and training can have a fundamental impact in improving health care globally. As an example, Cohen cited India as one of the most

privatized health systems in the world, with more than 70 percent of health delivery provided by private clinicians. India is also one of the most rural countries, which makes it extremely difficult to reach the entire population through the informal health sectors in rural areas. In addition, the level of care provided does not necessarily meet any local, national, or international standards. In Cohen’s experience, most of the development work provided by global agencies targets the public health sector. In a place like India, Cohen believes that there is an increasing acknowledgment that development goals cannot be met without addressing the private health sector. In other countries, Cohen noted, private equity investments through organizations such as The Abraaj Group are resulting in more accredited health delivery systems. Using this approach, Cohen postulated that private investment could include training and education for these private practitioners (as opposed to excluding them) and strengthen the accreditation system. Cohen experienced this successful model at BD, where significant investments have been made toward training, whether it is provided within laboratories or clinical practices, and he encourages the promotion of a sustainable business model that incorporates PPPs. He believes that if accomplished, it could add tremendous value in multiple ways toward strengthening a global health care system.

Bland reflected on Cohen’s points and stated that many of these ideas, concepts, and instruments have been around for a while and are referred to as PPPs. In terms of funding, however, there is far less money donated from private industries and the majority of global development comes from publicly funded organizations. That said, these models can work, and the private industry is comparable in terms of competence, innovative solutions, and important experiences. As an example, Bland mentioned when the British government worked with The Bill & Melinda Gates Foundation to incentivize private-sector donations with public funds. The British government agreed to a matching fund—every dollar donated by the private industry was matched by the government, dollar for dollar. It started small, but Bland said it was successful because once private funding was received it fundamentally changed the dynamic and reflected a PPP. Bland recalled that the first round of fundraising may have raised $8 or $10 million from the private sector, compared with the $4.3 billion that was raised by the public sector. Currently, Bland believes that about $300 to $400 million is donated by the private sector. This model reflects sharing risk across sectors. Bland also commented that the challenge has been to explain the innovative solutions and global impact in a meaningful way.

Vega offered another example of innovative financial incentives, stating that public-sector financing can be used to improve efficiencies within the private sector. In Chile, for example, the government has introduced a

system to pay for treating and improving the condition rather than paying by number of days that the patient stays in the hospital. The government purchases a set number of beds each year from the private sector, but then negotiates a rate for a specific diagnosis; thus, encouraging the private system to benchmark care and introduce efficiencies into the management of cases that are hospitalized. Vega summarized by observing that incentives can be from the private sector to the public sector, as well as from the public sector to private industries.

Cohen shared examples of innovative financing incentives, as well. At GBCHealth, Cohen in collaboration with others has been working on social impact bonds and other innovative funding mechanisms. Within this working group, the measurement of the ultimate impact of the work was felt to be lacking in many projects. One reason for this lack of long-term assessment was that most funds are provided prospectively, prior to impact. To address this work, the team has been collaborating with Paul Farmer from Partners in Health to develop a measurement system that leads to sustainable funding in conjunction with demonstrated results. The team believes that this system may expand the opportunity for increased private-sector financing and private donor financing, among those motivated to reinforce the positive outcomes. Another innovative financing concept that Cohen and his colleagues have been considering focuses on social impact credits or health impact credits. This concept is akin to what has been accomplished with carbon tax credits. In this scenario, there could be an incentive for private investment, such as easing regulatory barriers and/or accelerating review of new innovations. There are a number of incentives that could be used that have substantial benefits without actually requiring funding. These credits could become a secondary market, as they have become with carbon tax credits. For example, Tesla Motors makes more profit selling its carbon tax credits than it does on the manufacture of its cars. These credits have indeed become a key element of Tesla’s business model. Yet, this innovative approach has been lacking in the global health arena. Cohen suggested that these credits could be linked directly to the SDGs when they are launched. For example, could the SDG targets become the means by which social impact credits can be afforded to organizations that otherwise would not invest? Finally, Cohen pointed out that a lot of private capital is not currently being accessed. One of the models that BD is implementing is around strengthening the health care delivery for maternal and newborn health. To do this, BD has requested private capital to limit the impact this work has on profit and loss for the year; instead, providing a solid return to the private investors. This approach requires BD to prolong returns into the future, but overcomes near-term constraints and therefore avoids having to redeploy funds from existing core business operations while still sup-

porting societal needs. This model could unleash large sums of private capital.

TRANSPARENCY, COOPERATION, AND ACHIEVING THE SDGS

Jeffrey Sturchio from Rabin Martin provided a perspective not only on the incentives for different sectors to engage in PPPs for health systems strengthening, but also the importance of being transparent about those incentives. When developing a new partnership, it is necessary to be honest about what is in it for the private sector, what is in it for the government, what is in it for the NGOs, and what is in it for any other partners, Sturchio explained. Health systems strengthening partnerships provide companies with the opportunity to move into new markets and to conduct business in a different way in places where they have not had access before. Also, companies are as affected by poor health and related impacts on productivity as governments are, as well as anyone else living in a society. For that reason alone—because businesses have a stake in the societies in which they operate because they depend on workforces that are able to produce and not be affected by ill health—the private sector has a stake in health as a global public good.

Sturchio concluded by noting that there is clearly value for the public sector to engage with the private sector. Countries are trying to meet the targets set by the SDGs and, in his opinion, the only way to deal effectively with the complexities of the SDGs is for everybody who has skills and resources to contribute to potential solutions to be at the table and to find ways to collaborate. He believes this is a key reason why it is important for the private sector to be engaged. From a public-sector point of view, Sturchio added, engaging the private sector will also enhance economic growth and development.