Partnerships for health in the 21st century Ilona Kickbuscha & Jonathan Quickb
Introduction Partnerships for health have become an important mechanism for health development. Joint initiatives between the public sector, nongovernmental organizations and the corporate sector are increasing, both at country and at the international level. A growing number of policy statements, conferences and publications highlight the importance and necessity of building partnerships and illustrate the experiences gained. Partnerships for health have provided new opportunities for health creation and for putting across health messages (13 ). They have allowed for a wide ownership of health throughout society and have added a new dimension to intersectoral action for health. The importance of partnerships will continue to grow as new players enter the health arena and as it becomes accepted that significant health gains can only be achieved with the participation of sectors other than health (4). This development increases the number of actors in international health and has implications for the role of the World Health Organization (WHO). WHO must increasingly see its role as one of mustering support for health from many players for its health development agenda - both the unrmished business of child survival and the new challenges such as ageing of societies. It cannot tackle the immense threats to health - such as poverty- alone and through the health system. It needs strong partnerships between public bodies, civil society and the private sector to make health everybody's business. Acting as an initiator, catalyst and honest broker for health partnerships must become a dominant function of WHO's work. Therefore partnerships for health constitute a core component of the new WHO Health for All policy for the 21st century (HFA).c
Partnerships are a response to a changed environment Strengthening partnerships for health is a practical response to the changed environment at the end
of the 20th century. Traditional development resources are declining, privatization of government functions is increasing and private resource transfers to developing countries are expanding (5). The understanding that health is a critical factor in development - indeed a benchmark for development-is gaining ground and opening up opportunities for partnerships that address the broad range of health determinants and health needs. New information technology offers access to communication, information sharing and networking not possible before. The health industry itself has become a major development factor. Civil society organizations are increasingly actors (and watchdogs) in the development process (6). Six contextual factors underline the need to increase our understanding of partnership building: (i) Partnerships are becoming increasingly common in the health arena. (ii) The boundaries between sectors and between public and private, for-profit and non-profit are also becoming less clearly drawn. (iii) Increasingly national health agendas are influenced by regional groupings and arrangements. (iv) At the other end of the spectrum increased decentralization brings new responsibilities for health to the regional and local level. (v) Both the private sector and the NGO world are becoming more diversified. (vi) Partners appear in great diversity and in varied contexts; they cannot all be treated in the same fashion. WHO can of course look back on a long tradition of working with others: with other UN organizations, with the academic· community through Collaborating Centres, with NGOs through a range of mechanisms and with the private sector, in particular the pharmaceutical industry. For example, the progress achieved in global polio eradication (7) or in fighting onchocerciasis would not have been possible without dedicated commitment of partners at all levels of implementation. WHO has also pioneered new types of partnerships at the local level, for example, with local authorities through the WHO Healthy Cities Project.d
a
Director, Division of Health Promotion, Education and Communication, World Health Organization, Geneva. Director,Action Programme on Essential Drugs, World Health Organization, Geneva. d
b
c WH 0. Renewed healthjor-all strategy: draft policy for the twenty-first century. (EB100/2) Geneva, April1997.
WHO Regional Office for Europe. Tsouros, AD (ed). lW/0 healthy cities project, a project becomes a movement; review of progress 1987-1990. Copenhagen, 1991.
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Partnerships for health are evolving at all levels of society in both developed and developing countries: they range from involving the business sector in improving child health and survival and in combating HIVI AIDS, to global partnerships to support the International Water Decade and local alliances for health promotion (8). But a wide range of partners have not yet been tapped and WHO procedures do not always allow for a deeper involvement and recognition of new partners. This must change in order to allow for the full implementation of the new Health Policy for the 21st century.
The nature of partnerships for health The word "partnership" is increasingly being used and there may be as many definitions of partnership as there are partnerships themselves (9). A variety of types of partnerships are possible - ranging from alliances, coalitions, networks, consortia, collaboration, cooperation and sponsorship. A pragmatic definition for the purposes of health development could read: Partnerships for health bring together a set of actors for the common goal of improving the health of populations based on mutually agreed roles and principles. Perhaps more important than exact definitions is the agreement on the key principles in partnership building. Partnerships imply that a balance of power and influence is maintained between the partners and that each partner can retain its core values and identity. Successful partnerships are built on mutual respect and trust, transparency, and mutual benefit. The process of partnership building is key: roles need to be clarified, boundaries need to be drawn, added value needs to be defined. Ideally the partnership creates a synergy: each partner contributes "what it does best". For example WHO can bring its technical expertise and credibility, business its managerial expertise, marketing competence and logistics, NGOs their knowledge oflocal culture. In terms of delivery and outcomes, partnerships aim for the most productive delivery for maximum benefit. Well-managed partnerships lead to shared benefit and added value for all partners involved. As one advisor expressed succinctly: they make 2 plus 2 add up to 5. Thinking in terms of partnerships for health requires a different mind set: it aims to make health an attractive partnership option. Such an approach has two important dimensions: (i) through putting health on the agenda of other actors/sectors the health sector can significantly increase social momentum for health improvement; and (ii) in doing so, it can also increasingly help other sectors/actors understand how health can support them in reaching their own expressed goals and combine health with other benefits. Wid hlth statist. quart., 51 (1998)
For example, WHO is currently exploring increased cooperation with the World Tourist Organization and a range of other key players in the travel and tourist business, including government departments that promote tourism. The health issues addressed include vaccination, water and food safety, sexual health, workplace health and a range of lifetsyle issues. Travel and tourism is a volatile industry which can rapidly be affected by disease outbreaks - but also an industry which benefits from the increasing health and fitness interests of travelers. WHO's global outbreak surveillance network, its international health regulations, its occupational health regulations - all can benefit an economic sector that is of increasing importance to the developing world.
Categories of partnerships One way to encourage creative approaches to partnerships is to consider the various categories of partnerships. Partnerships may be based on existing products, product development, services, systems and settings, issues, health messages, or knowledge exchange (see Box 1). WHO experience with developing a refrigerator for vaccines in developing countries provides a useful example of a product-based partnership. WHO sent letters to 13 companies asking them to develop a refrigerator for vaccines adapted for use in tropical climates. Three companies responded and in the end two continued to discuss possible designs. WHO provided the knowledge about circumstances, and the companies designed the product at their own cost and risk. Electrolux was the only company to continue this process to production. They sold many thousands as vaccine refrigerators and for other uses. WHO regularly assessed whether the product fulfilled its function. Today, well-adapted refrigerators for use in tropical climates are available to conserve vaccines and for other purposes.e Knowledge exchange is the major part of partnerships, especially in a partnership with an intersectoral approach. One example of a knowledgebased partnership is a three-year project ( 19921995) with the WHO Collaborating Centre in Occupational Health and Health Promotion in Shanghai. In this Workplace Health Promotion Project, four enterprises affiliated to the metallurgical, shipbuilding, textile and chemical industries in Shanghai increased awareness of occupational health and the necessity of health promotion at the working place for employees and employers.£
e WHO. Global Programme for Vaccines and Immunization: Vaccine supply and quality; global training network. Geneva, 1997. f
WHO. Global strategy on occupational health for all. (WHA 49.12) Geneva, 1996.
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Box 1 Categories of partnerships Category of partnership Examples
Product-based partnerships
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Deworming drugs for children Nicotine-replacement therapy Aspirin for post-miocardia! infarction patients Cellular phones for remote clinics Designing a refrigerator for vaccines for use in developing countries
Product development partnerships Systems-based and settings-based partnerships -
Healthy cities Safe workplaces Health-promoting schools Polio eradication Tobacco control Food fortification
Issue-based partnerships
Health-message-based partnerships
Joint campaigns: - WHO I UNESCO global malaria strategy - for healthy lifestyles - against drunk driving - for road safety Workplace health promotion project (see text)
Knowledge-based partnerships
Partnerships can also be organized around a WHO endorsement or "seal of approval" for a product, service or system; a range of signing-up approaches for a "health company" or "healthy city"; or regular benchmark health surveys. Examples of such partnerships might include the following: • a WHO "seal of approval" for airlines which are smoke free and serve healthy food; • a "signing-up" approach in which WHO establishes an index for a "healthy company" and a network that helps companies to move towards these criteria; • regular "benchmark health surveys" similar to the "Benchmark Corporate Environmental Survey" conducted by the UNCTAD Programme on Transnational Corporations (10). Growth in the number of such partnerships for health would help to isolate products or services clearly damaging to health. Consumer groups and the media could play a key role in advocating the best practice. It would allow WHO to systematically expand its role as a broker for significant health development challenges.
Networks Increasingly partnerships are organized through networks. WHO has created and is actively involved in many such networks. They thrive on partnerships at all levels of their implementation- among the members of the networks, between the networks and WHO, between one network with other WHO networks. The potential of this asset has not been fully exploited by WHO; networks are fre70
quently still seen as a chance effect rather than as a management tool for partnerships. Networks reflect a more egalitarian, non-hierarchical style of partnership building. A network is described as a "grouping of individuals, organizations and agencies, organized generally on a non-hierarchical basis, around some common theme or concerns". Networking for health implies interlinking individuals, groups, institutions and organizations with an interest in health. Their purpose is usually to exchange information and experience; to work together for a common aim; or to advocate a specific position or action. At their best they jointly develop and provide solutions so that the knowledge developed in one part of the network becomes a joint resource and a public good. In recent years WHO has built anumber of new setting-based networks. Networks typically have a specific focus. Settings for health projects, many linked officially through WHO networks, include the following: Healthy Cities, Healthy Villages, Healthy Islands, Health Promoting Hospitals, Baby-friendly Hospitals, Healthy Schools Project, Healthy Prisons, Healthy Market Places, Healthy Workplaces, Sports Venues, and Countrywide Integrated Noncommunicable Disease Intervention Programme (CINDI).
Principles and criteria for partnerships In a complex, rapidly changing environment, old mechanisms do not always provide solutions, indeed they can become counterproductive. The relations between health organizations and agencies and their partners will not be as predefined and Rapp. trimest. statist. sanit. mond., 51 (1998)
straightforward as in the past. Opportunistic and highly flexible responses will be necessary, speed will be of the essence. This makes it all the more necessary to be clear about the principles, the criteria and the process of partnership building and maintenance. Next to the general principles of partnership building - mutual respect and trust; transparency and mutual benefit - partnerships for health should be built on the health for all value system as outlined in the new HFA policy: human rights; equity; ethics; and gender perspective. Because developing partnerships requires human and usually financial resources, a judgment must be made early in the process as to whether the added value of the partnerships (potential health gains) will be worth the effort involved in establishing and maintaining the partnership. Criteria for health partnerships might differ at local and national level and in specific circumstances. WHO as an international organization will need to revisit the way it works with its many partners. Partnerships should meet basic criteria: • The partnership should lead to significant health gains. • The health gains should be worth the effort involved in establishing and maintaining the partnership.
NGOs and industry umbrella groups, there is often excellent scope for cooperation on specific population health issues. The cooperation ofWHO with the food industry in promoting global food safety shows this. Selection of NGOs for partnerships should be based primarily on the scope and magnitude of the expected health gain and not on whether the NGO is international in character or has other specific features which may not be relevant to a successful partnership. At the same time, an NGO must be generally recognized in its field and it must have an established record of achievement. It also should meet certain basic organizational and financial management requirements.
Partnerships with the academic sector The academic sector represents a source of expertise, technology transfer, and training of the human resources of tomorrow. Much can be done to maximize this very important resource network in its work with WHO (13), through out-sourcing, competitive bids etc. and through partnerships with academic disciplines beyond the health area, such as education, management, economics, law, policy sciences, communication and promotion. Moreover, the fact that many research institutions are private rather than public requires careful consideration in order to ensure independent and authoritative advice, and general access to health information. Knowledge management at a global level is becoming ever more important and WHO must see itself as the hub of a global knowledge partnership for health development. This also means assisting centres throughout the world in working towards the same high standards and being members of a global community of health knowledge (14 ). These centres explore new ways of working together, new types of comparative and global analysis and are involved in the search for common solutions.
Partnerships with NGOs In addition to the present mechanisms of working relationships between WHO and NGOs, there is a need for a wider spectrum of NGO relations, including an evaluated and institutionalized dialogue. The types of NGOs differ considerably and provide alternative views to those of governments (11, 12). This diversity is important for an effective improvement of health. New types of NGOs need to be included as for example urban leagues and associations of Mayors in order to promote the urban health agenda. Different types and levels of relationships between NGOs and WHO are needed in order to reflect the diversity of NGOs. While there can be significant differences between action-oriented
Partnerships with the corporate sector Partnerships with the corporate sector at all levels from global to local are essential (15). The inter-
Box 2 Collaborating centres There is a need to make maximum use of the existing arrangements with the collaborating centres which primarily provide access to the academic sector and research community. Much can be done to maximize this very important resource network, through outsourcing, competitive bids etc. But the approach to designating collaborating centres should be revised and made more effective, and the achievement of the criteria should be controlled carefully every four years to protect a good collaboration and the well-deserved title. Furthermore, the academic sector could also be included beyond the health area, in education, management, economics, law, policy sciences, communication and promotion. Moreover, the fact that many academic institutions are rather private than public raises the question about independent and authoritative advice, and about general access to health information.
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national health community must engage the powerful private development forces in the struggle for better health. Of course this includes areas such as occupational health and safety, the minimization of pollution and the ecological impact of the industry, but also the promotion of health values and a public service role for private industry. In developing partnerships with the corporate sector WHO's reputation as an impartial holder of health values must be ensured. Up to now, this type of cooperation has been mainly with umbrella groups of the private sector - but increasingly individual companies are keen to contribute to health development. A WHO working group on partnerships identified a set of issues which must be addressed when considering partnerships:
(iii) Appropriateness of the individual activity Partnerships often focus on a specific activity or set of activities. Most categories of activities proposed in the context of a WHO partnership will be appropriate, since they will aim at specific health policies or health practices. However, the following categories of activities are not appropriate within a WHO partnership: • Activities which involve conflict of interest or perceived conflict of interest. • Activities which benefit the corporate partner, but provide no clear benefit to health, to WHO or to Member States. Conflict of interest is of particular concern for WHO programmes involved in setting regulatory standards and other norms which may affect product costs, market demand, or profitability of specific goods and services. Examples include norms for quality, safety, efficacy, promotion practices, and information accuracy for pharmaceuticals; norms for registration of herbal and other traditional medicines; chemical safety standards; and nutritional guidelines. To avoid conflict of interest- real or perceived -the concerned WHO programmes must establish procedures which ensure that: (a) final normative decisions are free from undue influence; (b) industry funding is not used for salaries of staff involved in normative decisions; and (c) consultations and other normative activities never have their majority financing from the concerned industry. In the context of an ongoing partnership, some proposed activities may service public relations and other interests of the external partners, but have no clear health benefit. In general, such activities should be avoided. A mechanism for regular dialogue with the broad scope of the private sector with an interest in health should be established - as is being considered in other UN organizations. The risks involved in developing partnerships with the corporate sector are also considerable. They include the possibilities that (a) the WHO reputation will be used to sell goods and services for corporate gain, thus tarnishing WHO's reputation as an impartial holder of health values; (b) WHO's judgement on a particular product, service, or corporate practice may be compromised by financial support provided by the involved company or industry; and (c) WHO involvement with an industry or company is perceived as acceptance of unhealthy products, services, or practices.
(i) WHO policy toward the industry involved The involved industry must be a suitable partner for WHO. The following questions should be asked when developing a policy toward a specific industry: • Are the major products or services of the industry harmful to health? • Does the industry engage on a large scale in practices which are detrimental to health? • Is the influence of WHO's role in the partnership likely to do more good than the damage done by harmful practices, products or services? Health provider organizations, the pharmaceutical industry, health care technology industries and similar organizations are generally quite suitable partners. The tobacco and arms industries, which have indisputably negative health impacts, are clearly not suitable partners. Many industries such as transportation industry, food industry, and chemical industry have both a positive and a negative impact on health. For those industries it is essential that WHO formulate a specific policy on the industry.
(ii) Suitability of the individual company Even when an industry is a suitable partner, individual companies may not be. Evaluation criteria might be used which are similar to those already being applied by a range of public agencies in evaluating potential private sector partnerships. These factors include the occupational health conditions on which products or services are produced, the environmental commitment of the company, the marketing and advertising practices of the company, the research and development policy and practice of the company, the regulatory compliance of the company and past activities which might reflect poorly on the credibility of WHO.
The process of building and maintaining partnerships Partnerships do not just come about; they need to be built with skill, care and mutual trust (16, 17). A Rapp. trimest. statist. sanit. mond., 51 (1998)
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partnership strategy needs to constantly bear m mind each of the following steps: identifYing opportunities; identifying potential partners; selecting the most suitable partners; negotiating/reaching a clear partnership agreement; maintaining the partnership; and regularly evaluating the partnership. WHO is in a unique position to identify opportunities for partnerships in health development. It has a global view of priorities and needs, is already in contact with a wide range of actors and has the standing and authority to approach new players. In identifying partners WHO should always try to be inclusive instead of exclusive. Equal access possibilities for different partners should be provided whenever possible. WHO should maintain an open and fair process in developing partnerships with several associates on similar projects. Establishing partnerships consumes time and resources, especially at the beginning. But if the partnership is well-chosen, it should save time and improve results once it is underway. Plans of action are a well-established procedure used with WHO Collaborating Centres and, for example, with the WHO Healthy Cities "City Health Plan". Plans include, among other things, a clear cut goal of the partnership, measurable project objectives, human and financial resources and other contributions, responsibilities of each partner, conditions and mechanisms for amendments or termination of the agreement, and a timetable. Regular communication, training and close monitoring increase trust, coordination and avoid misunderstanding. This guarantees common approaches and further commitments, thus maintaining the partnership and assuring its success. Finally, the partnership should be regularly evaluated. The partnership agreement or plan of action should provide criteria or indicators for measuring progress, success or failure. Periodic evaluation is essential to determine whether the partnership is achieving its objectives. Evaluation is also necessary to determine whether the partnership should be expanded, contracted, or terminated. For WHO and similar health organizations, it is essential that partnerships achieve health gains.
Conclusions It is essential for WHO to accept that within a changed environment, one of the key roles of the health sector is to initiate partnerships that leverage health. WHO will need to enter into partnerships at different levels within each "partner-category" in addition to the existing relations. WHO's organizational culture needs to be more responsive to lateral relationships and networking among many actors. The present vertical organization is not conducive to information sharing and network Wid hlth statist. quart., 51 (1998)
building. Successful partnership building does not enjoy the same status as successful fund raising of a classical nature. Staff need to understand the power of partnerships and be trained in partnership building. The following actions may help to strengthen the culture for partnership within WHO: • An information base listing all WHO partners, their nature, characteristics of the special partnerships, action plans and related subjects is essential, model contracts and agreements should be easily accessible. A partnership unit should help monitor partnerships, help analyze and evaluate them and provide assistance in partnership building. For a successful protection of WHO's reputation an internal database of unaccepted partners and failed partnerships must be established, listing the reasons for failure. Such an information base could assure unified approaches and procedures. • A strategic entity (i.e. a partnerships unit) needs to help develop new partnerships based on HFA and help maintain and strengthen existing partnerships as well as providing new impulse. This unit would actively help programmes to build, cultivate and coordinate networks. This will be the coordinating centre of the new broader spectrum of external relations. It would help prevent duplication of effort, confusion and waste and assist with networking the networks. Some internal working groups to this effect already exist such as the WHO HQ working group on healthy cities. • Guidelines for partnerships must be developed together with potential partners and presented to the governing bodies. • Annual "HFA partnership meetings" that assess progress in partnerships for health in the 21st century should be established beyond individual programmes, donors should be advised of the experiences gained with a network and partnership approach. • Publications can summarize process and successes of a partnership and motivate other institutes to contribute resources to partnerships. Partnerships for health will result in joint action that will lead to the attainment of common predefined goals. Additional benefits are likely to be generated over time as a culture develops of all those involved in HFA. A partnership for health approach also has consequences for both training and research in public health. Training institutions must teach the skills needed to form and maintain partnerships and a future-oriented research agenda must study existing (and failed) partnerships with a view to developing evaluation tools. Increasingly the health sector at all levels will be called upon to play a motivational and brokerage role for new types of partnerships for health development. It is only appropriate that WHO should take the lead in such a development. 73
Acknowledgments This paper is a shortened and reworked version of a document produced by the Working Group on Partnerships for Health in the 21st century which was chaired by Ilona Kickbusch. We thank all members of the working group for their contribution and apologize for not being able to reflect all the issues raised and proposals made by the group because of lack of space. Members of the Working Group: Dr C.M. Chollat-Traquet, Dr N.E. Collishaw, Mr S.S. Fluss, Dr T. Codal, Dr G. Goldstein, Dr M. Jancloes, Dr F. K.aferstein, Dr Y. Kawaguchi, Dr I.Kickbusch, Dr J.D. Martin, Ms A. Mohrle, Dr D. O'Byrne, Dr]. Quick, Dr J.L. Tulloch, and Dr D. Yach.
important du developpement sanitaire, et souligne qu'il appartient a I'OMS de considerer que son role sera de plus en plus de trouver l'appui de nombreux acteurs de Ia sante. Pour cela, I'OMS doit modifier sa «culture institutionnelle, et Ia fa<;:on dont elle opere.
References - References 1. Health Education Authority. Promoting health in partnerships with the health education authority; an invitation to the pharmaceutical industry. London, 1997. 2. Kerr, M. Partnering and health development; the Kathmandu connection. Calgary, Ottawa, University of Calgary Press, International Development Research Centre, 1996. 3. van der Gaag,J. Private and public initiatives; working togetherfor health and education. Washington DC, The World Bank, 1995. 4. Kickbusch, I. New players for a new era: responding to the global public health challenges. journal of public health medicine, 9(2): 171-178, Oxford University Press, 1997. 5. UNRISD (United Nations Research Institute for Social Development). States ofdisarray; the social effects ofglobalization. London, UNRISD, 1995. 6. NGLS (UN Non-Governmental Liaison Service). The United Nations, NGOs and global governance; challenges for the 21st century. UNCTAD/NGLS/64. Geneva, 1996. 7. Soilver, C. Rotary's polioplus. World health, 48th Year, No. 1 (1995). 8. Scriven, A. (ed.). Alliances in health promotion: theory and practice. London, Macmillan, 1998. 9. Wilson L & Wilson H. Stop selling, start partnering. New York, John Wiley & Sons, Inc., 1997. 10. UNCTAD (United Nations Conference on Trade and Development Programme on Transnational Corporations). Environmental management in transnational corporations; report on the benchmark corporate environmental survey. New York, United Nations, 1993. 11. Green, A & Matthias, A. How should governments view nongovernmental organizations? World health forum, 17: 42 (1996). 12. Ritchie, MA et al. Roles and approaches of nongovernmental organizations in health development. World Health Forum, 16: 36, 1995. 13. Sheldon, T. Call for European cooperation in research. British medical journal, 314: 1300 (1997). 14. Uusitalo, T & Chowpradith L. Internet as a tool for distribution of occupational health and safety information. Asian-pacific newsletter on occupational health and safety, 2: 54-55 (1995). 15. Slater, S & Saade, C. Mobilizing the commercial sector for public health objectives- a practical guide. USAID, BASICS & UN! CEF, 1996. 16. Tennyson, R. Tools for partnership-building. London, The Prince ofWales Business Leaders Forum, 1994. (Partnership Handbook Series No.2). 17. Richards, RW (ed.). Building partnerships; educating health professionals for the communities they serve. San Francisco,JosseyBass Publishers, 1996.
Summary This paper presents the results of a working group on partnerships in preparation for the WHO Health for All Policy for the 21st Century. The working group aimed to clarify the nature of partnerships for health, proposed six categories of partnerships and outlined principles and criteria for partnerships. It concluded that partnership building was a key strategic component of health development and underlined that WHO must increasingly see its role as one of mustering support for health from many players. In order to do so, WHO must change its organizational culture and mode of operation.
Resume Partenariats pour Ia sante au XXIe siecle Cet article presente les resultats d'un groupe de travail sur les partenariats en preparation concernant Ia politique OMS de Ia Sante pour tous pour le XXI 8 siecle. Le groupe de travail cherche a elucider Ia nature des partenariats possibles en matiere de sante, propose six categories de partenariats et esquisse les principes et criteres retenus a cette fin. Le groupe conclut que Ia creation de partenariats est un element strategique
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