# 8.1 Introduction ## Learning outcomes By the end of this session, you should be able to: - Understand the historical development of GHPs; - Define GHPs, differentiate between the various types of partnerships, and distinguish partnerships from other forms of global health cooperation; - Summarise, with examples, the organisational, governance, and policy challenges that partnerships face; - Synthesize research on the effects of GHPs on countries’ health systems GHPs are a new and radical breed of global cooperative arrangements involving public and private-for-profit actors – typically governments, Non-Governmental Organisations (NGOs) and research and development (R&D) pharmaceutical companies. Some GHPs now represent a significant conduit of aid funds to the health sector – displacing traditional bilateral aid – and introducing new ways of doing business. For example, the Global Fund to Fight AIDS, TB and Malaria and the GAVI Alliance are much more performance-oriented and they place greater emphasis on delivery through the private sector and NGOs than do many traditional donors. These new forms of partnerships impacted multilateral organizations such as [[World Health Organization (WHO)]] both in global and country level. In short, GHPs have a central role in determining, ultimately, what gets funded and delivered on the ground (and to whom and on what conditions). GHPs represent a fundamental shift in the architecture of [[global health governance]], the implications of which we are just beginning to grasp. # 8.2 Defining [[global health partnerships]] Characterised by increasing number of [[Non-state actors]] and the introduction of new coordinated ways to respond to some of the world's most neglected health problems. For the purposes of this lecture, ==public actors== include governments and international organisations whose members are governments (such as those within the United Nations family of organisations - e.g. the World Health Organisation or UNAIDS), while ==private actors== include not-for-profit non-governmental organisations [[NGO]] and civil society groups (e.g. Médecins Sans Frontières) and for-profit institutions such as multinational companies (e.g. pharmaceutical giant MERCK) and private foundations such as the [[Bill & Melinda Gates Foundation]]. You can see where GHPs fit in this Venn diagram. > “A collaborative relationship which transcends national boundaries and brings together at least three parties, among them a corporation (and/or industry association) and an intergovernmental organisation, so as to achieve a shared health-creating goal on the basis of a mutually agreed division of labour” [[@buseGlobalPublicPrivate2000]] Let’s look at an example, in fact the very first GHP. The Mectizan Donation Program was established in 1987 to oversee Merck & Co., Inc.'s donation of Mectizan for the control of onchocerciasis worldwide. In 1998, Merck expanded the mandate of the program to include lymphatic filariasis elimination through the co-administration of Mectizan and albendazole, donated by GlaxoSmithKline, in African countries and Yemen where lymphatic filariasis and onchocerciasis are co-endemic. As of the end of 2011, 140 million treatments were being approved annually by the Mectizan Donation Program for onchocerciasis and 130 million for lymphatic filariasis. The success of both programs is largely due to the partnerships that have evolved in support of both disease control and elimination initiatives over the last three decades. # 8.3 History and function of [[global health partnerships]] ## Early Developments Historically, not-for-profit private organisations, such as mission hospitals, have been providing health care since the 19th Century, while the [[World Health Organization (WHO)]] has been interacting with the business community, albeit frostily, since its inception. the business community, albeit frostily, since its inception. ==What is different, and here we come to the crux of what makes Global Health Partnerships unique, is the nature of the interaction between public and private actors.== An early critic of GHPs argued that the fundamental novelty of the partnership response to global health issues was its “new mental model” (Richter, 2004: 45), which captures the difference nicely. > GHPs have become a dominant mode of interaction between the various national, international, public, and private actors involved in [[global health governance]]. ### Table 1. Summary of key moments in the rise of GHPs | 1992 | Rio Earth Summit and 'Agenda 21' | | ---- | ---- | | 1998 | UN Habitat II Meeting and publication of the OECD DAC report ‘Shaping the 21st Century’ | | 1998 | [[Gro Harlem Brundtland]] at WHO | | 1999 | The [[Bill and Melinda Gates Foundation]] | | 2003 | Follow up DAC High Level Forum on aid effectiveness discussed | | 2007 | Launch of the [[International Health Partnership (IHP+)]] | Also in 1996, the Habitat II United Nations Conference on Human Settlements was the first time that the UN expressed its commitment to public-private partnership as a guiding principle of future interventions. It is perhaps no surprise then that Gro Harlem Brundtland, ==the person often credited with introducing the notion of public-private partnerships to global health==, spent her early career in the development field. > “Only through new and innovative partnerships” she argued, “we can make a difference”. > — [[Gro Harlem Brundtland]] Partnership soon became a mantra for the Organization’s higher echelon, with Brundtland’s successor Jong-wook Lee stating just a few years later that “Partnership with private and public sector actors is not simply a choice. It is the only possible way forward”. Despite Brundtland’s endorsement, WHO’s relations with the private for-profit sector has been something of a roller-coaster ride. There are reasons why GHPS emerged when they did and these are described in the core reading by [[@buseSevenHabitsHighly2007]] and in an article by Roy Widdus (2005). > There is a more fundamental criticism of GHPs that is a by-product of critiques of globalisation and global governance. As we have seen in [[GHM102 Session 05 The role of state in global health]] on the role of the states in global health policy, in the political sciences there are at least two perspectives of world order that are profoundly critical of either the possibility or the desirability of cooperation between countries and other actors. The first is Realism (which argues that the world is inherently anarchic and states are fundamentally self-interested; as a result, we need to face up to the reality that these conditions will always make cooperation a fool’s errand). The other is Marxism (which argues that the current capitalist system is the root cause of all of our political and social ills and must be dismantled before we can ever hope to develop). > “If you reject globalisation, global corporations or even the system of capitalism itself, then you won’t like what we’re doing at all”. > — John Ruggie This lecture is not the place to explore counter-arguments to globalisation and global health governance, but it is worth noting that one prominent proponent of an early international partnership – the Global Compact – addressed such critiques directly. In defence of his work, John Ruggie asserted: “If you reject globalisation, global corporations or even the system of capitalism itself, then you won’t like what we’re doing at all”. ## Functions of GHPs Widdus (2005), for example, cites in excess of 100 public-private partnerships. Buse and Harmer (2007), on the other hand, argue in the second of your essential readings, that if one of the defining characteristics of a GHP is that both public and private sector representatives have a *meaningful voice* on the decision-making process of the partnership (i.e. at the level of the Board of Directors – which is where the real decision-making takes place) then we barely get into double figures. ==The worry for these authors is that an essential quality of partnerships – its representativeness – will be lost as GHPs evolve or are subsumed under broader categories such as Global Health Initiatives ==(we will return to GHIs a little later). Different categories of GHPs — based on what? One typology categorises them according to different aspects of their institutional structure, for example whether they are hosted by a multilateral orgnisation, managed by NGOs, or are legally independent partnerships that are managed separately from public and private partners. Another way to categorise is according to their function - what is it that they do? Here are some examples of what GHPs do, based on a typology proposed by the UK Department for International Development ### 1. Product-based partnerships Primarily drug donation programmes that are established after a drug is found to be effective in treating a condition for which there is limited demand due to lack of willingness and ability to pay – e.g. it is effective in treating a disease associated with poverty. Usually, a pharmaceutical company will seek partnership with the public sector to lower the cost of the drug and to ensure the chance that it will reach those who need it. ### 2. Product-development partnerships Product-based partnerships and product development partnerships are actually triggered by the same problem: ==the small size of the market for certain products==. In the first case – the product-based partnerships– it is poor people’s inability to pay for an already existing drug that triggers demand. In the case of product-development partnerships, demand arises when people cannot afford to pay for a new drug in the future (which reduces incentives for companies to invest in R&D). With product development partnerships, the public partner assumes a number of risks associated with product discovery by providing a subsidy. This makes partnership more attractive to a private investor that is guaranteed a return (even if it is modest), it can gain public good will, and may see value in being involved in the standard setting and regulatory process. Some notable examples of this type of GHP are: the International AIDS Vaccine Initiative (IAVI), which was established in 1996, and the Medicines for Malaria Venture established two years later. #to-read [[International AIDS Vaccine Initiative (IAVI)]] and Medicines for Malaria Venture ### 3. Systems or issues partnerships The third type are systems or issues partnerships. These are high-profile partnerships that seek to harmonise efforts by multiple partners around a specific issue – for example the Roll Back Malaria campaign or the Stop TB Partnership. They are set up to address health systems issues; Recent work by the Global Fund to Fight AIDS, Tuberculosis and Malaria and the GAVI Alliance are examples of a new development where partnerships contribute to health systems strengthening as well as supporting specific diseases. ### 4. Financing partnerships Such as the [[Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM)]]. The Global Fund exists to raise and disburse money committed by its partners to countries around the world. In the 2022 replenishment conference, Global Fund partners pledged a total contribution of US $14.25 billion to support the partnership’s work over the next three years. Emerging economies and implementing partner countries also made pledges, including Indonesia, Malawi, Morocco, Paraguay, and Tanzania. ## [[Question]] What is so special about [[global health partnerships]]? 1. ==They are a forum for the exchange of ideas and values== – a place where public and private actors that wouldn’t normally get together can meet and share ideas for addressing global health problems. This forum simply didn’t exist twenty years ago. 2. ==They re-define public and private sector actors as partners with clearly defined roles, responsibilities, and expectations about appropriate behaviour.== Transgressors lose credibility as bad partners; good partners earn respect and praise. Crucially, partners learn from one another, and by increments their identities are re-shaped: from public or private to public-private partners. 3. ==They function as an accountability mechanism==. Being a partner matters because commitments made are made transparently, documented, uploaded to the partnership’s website and thus available for scrutiny by the global health community. The Global Fund and the GAVI Alliance have championed this global public-private good and more recent partnerships, such as the International Health Partnership, are following in their footsteps. If the public and private sectors want to hold each other to account, then global health public-private partnerships are one way that they can do this in the health sector. ## Shifting terminology - from partnerships to initiatives Language evolves rapidly, and in recent years we have witnessed a drift in terminology from “global health public-private partnership” to “global health partnership” and, most recently, to “global health initiatives”. With each subtle shift in terminology, the danger is that the quintessential features of global health partnerships are lost: open space and minds to share different values; a learning environment for public and private sectors; and accountability and transparency. The term global health initiative (GHI), for example, is not the same as global health partnership. The Global Fund, bilateral initiatives such as the President’s Emergency Plan for AIDS Relief (PEPFAR), and international economic organisations such as the [[World Bank (WB)]] are frequently lumped together primarily on account of their wallets, which contribute to almost two-thirds of external financial support for HIV/AIDS control in low-income countries. Whilst it makes sense, and is clearly important, to analyse and synthesize their aggregate impact on health systems, as a unit of analysis there is little else that these three funding sources have in common that would make comparison meaningful. To summarise what we have learned so far, there are three points to make. 1. First, as we saw with our definition – a global health public-private partnership is a partnership between at least three parties: The public sector (usually governments represented directly by ministers, or indirectly through membership of an inter-governmental organisation), the private for-profit sector (often the pharmaceutical industry), and the private not-for-profit sector (typically a non-governmental organisation). 2. Second, there are different types of GHP – product-based partnerships that often take the form of a drug donation programme; product development partnerships that seek to create incentives for the private sector to engage in R&D for otherwise neglected diseases; systems/issues partnerships and financing partnerships. 3. Third, GHPs perform different functions: they are a forum for discussion between public and private sectors; they help re-define actors’ identities (as partners in a partnership); and they act as an accountability mechanism. # 8.4 [[global health partnerships]] and [[global governance]] ![[CleanShot 2024-03-03 at 16.18.00.png]] As this image illustrates, governance in the health sector involves many different health organisations and professional groups. National governance occurs inside the ‘egg’ where government (dark blue) and state institutions (yellow), private sector (orange), and other health groups (light blue) help to steer society in a direction that is good for the health of the population. But there is an international and global dimension too: a world ‘out there’ beyond the boundaries of the nation-state. International organisations (in green) such as the World Health Organization, and global actors, such as GHPs, interact with national governments, agree rules and establish normal ways of working together. This is what we mean when we talk about global governance. There are a number of common terms that are used to describe different elements of governance. And each has a direct relevance to GHPs, including: - Legitimacy - Transparency - Effectiveness - Accountability - Representation In recent years we have witnessed attempts by GHPs to improve on governance practices. Let’s look at three of these elements of governance – accountability, representation, and transparency – in more detail. ## Accountability GHPs have attached new conditions to their funding arrangements. Both the GAVI Alliance and the Global Fund, for example, have set preconditions for funding and then modulated disbursement against performance and results. The partnerships have also experimented with new ways to assess and manage fiduciary risk – relying on private accountancy firms in a way that was not the case even ten years ago. In the case of the Global Fund, for example, a Local Funding Agent oversees the management of the grants. When things go wrong, GHPs have proven to be open and transparent, minimising damage and retaining trust – an essential condition for financing partnerships that rely on their reputation and integrity to maintain sustained donors’ funding. For example, the Global Fund in January 2011 was embroiled in controversy over the alleged fraudulent use of its money by some recipient country governments. Some partners of the Fund (Sweden and Germany) withdrew their support, albeit temporarily. However, the response by the Fund was immediate, effective, and transparent, acknowledging the problem through various media. ## Representation GHPs have also introduced new ways of approaching representation in the health sector. New constituencies, such as the commercial sector and civil society have been brought formally into planning processes at the global and national levels through a number of GHP instruments. [[Governance refers to the web of formal and informal institutions, rules, norms, and expectations which govern behaviour in societies and without which the very idea of a human society is impossible|A variety of formal and informal means to consult and hence share power have been devised]]. New and sophisticated efforts in stakeholder involvement have been developed – particularly by the Global Fund – as have methods to undertake the challenging task of collaborative multi-partner planning and monitoring. In developing these new approaches to collaboration, new pathways of influence have been introduced by GHPs – the more direct relationship between senior UN officials and the private sector constitutes just the most visible of these. ## Transparency Over the years, GHPs have increasingly recognized the importance of transparency in the conduct of their operations. Today, for example, it is easier to find information about the governance structure of GHPs than it was in the past – often there are readily available links on homepages. In 2013, an investigation in Cambodia found that two international companies paid “commissions” to Cambodian officials to secure contracts for the supply of anti-malaria bednets, paid with Global Fund monies. As a result, the Global Fund introduced new financial oversight mechanisms in the country and major suppliers are now subject to mandatory compliance regulations and a stricter code of conduct. Corruption is an ever-present reality in many countries, and certainly not just developing countries. This does show however that GHPs have embraced measures to improve corruption and, where it is discovered on their own doorsteps – have been open and transparent about it. The Global Fund even won praise from transparency NGOs for its response to corruption cases. ## GHPs and public relations In addition to championing good governance, GHPs have also been particularly successful in raising the profile of certain diseases on policy agendas, by concentrating on brand-building and public relations. For example, Product Red is asimple idea for raising money for the Global Fund. Well-known high-street brands such as Apple, American Express, Penguin books, Dell computers and others create a new product and 50% of sales of that product go to the Global Fund. It is not just through branding that GHPs have proven to be highly innovative in raising funds. In an effort to address problems associated with short-term funding cycles, the International Finance Facility for Immunisation (IFFIm) was launched by the GAVI Alliance in 2006. The IFFIm is an innovative mechanism through which national donors raise up-front money by issuing bonds which are paid back over 23 years. From 2006 through 2021, IFFIm’s donors - Australia, Brazil, France, Italy, the Netherlands, Norway, South Africa, Spain, Sweden and the UK – have pledged to contribute US$ 8.9 billion to IFFIm. These funds are used to repay IFFIm bondholders. The impact of “vaccine bonds” has been considerable, enabling GAVI to immunise 80 million children and contributing overall to saving more than 13 million lives from 2006 to 2019. More recently, this financing arrangement has been used to support access to COVID-19 vaccines in LMICs and build the COVAX Pandemic Vaccine Pool, a collaboration involving GAVI, the Coalition for Epidemic Preparedness Innovations, the World Health Organization, and UNICEF. Through innovations such as Product Red and IFFIm, GHPs have been particularly successful at reorienting the priorities of the health sector – the ultimate litmus test of GHG – for better and for worse. Nowhere is this more evident than in the case of financing for HIV – thanks mainly to the Global Fund. However, some have begun to question whether funding priorities match public health needs. The level of ‘success’ of HIV GHPs may not be fully known for some time, but already the effects are felt in relation to the neglect of other disease areas, as we will see in the next section. #to-read Product Red and IFFIm ## 8.4 Activity Take a moment to think about each of these terms (legitimacy, representation, accountability, transparency, effectiveness). They are quite abstract but see if you can write down how you might apply them to GHPs.  For example, a GHP is _legitimate_ to the extent that its authority is respected by those affected by what the partnership does. But this raises questions such as:  - Who is affected by GHPs and how do we know that they consider GHPs to be legitimate? - Is there a way for those affected to feedback their satisfaction or dissatisfaction to the GHP? Try to write down ideas about how a partnership can or should be representative, accountable, transparent, and effective, or what you think these terms mean with relation to GHPs. ### Answer - Legitimacy: GHP is legitimate if it is established after formal consultation processes between States as the 'sovereign decision-maker' for the people they serve and all relevant parties/organisations. However, the GHPs must provide a robust monitoring and evaluation mechanism in which everyone involved and affected by the partnership could have access to give power to their voice in the decision-making processes. - Representation: GHP must take into account the existing the deep core of neoliberalism, as framed by Rushton (2012), that resulted in health inequalities and power disparity. - Accountability: Apart from financing partnership - which has been included in the lecture notes, the other functions of GHPs must be held accountable in relation to other stakeholders with different paradigms of global health policy-making, such as human rights, security, economy, and moral. - Transparency: Applying transparency to GHPs can be tied to a publicly available, consistent update on how the partnership is going - Effectiveness: GHP must also think about how existing 'spaghetti bowl' of agreements, initiatives, and other partnerships that might overlap and/or compete with one another. # 8.5 [[global health partnerships]] and health systems > What are the effects of GHPs on country health systems? As important to the global governance effects that GHPs have had are the effects that GHPs have on countries’ health systems. ## Scaling up Health Services Unfortunately, scale up of funding has not always translated into significant increases in the health workforce. Some rural areas - where HIV/AIDS services are most neglected – have received proportionately fewer staff than urban areas, and increases in staff for non-clinical HIV/AIDS services are not replicated for clinical services. In most countries the national health workforce has not grown proportionately to the increasing number of clients seeking care and treatment for HIV/AIDS. ==As a result, workloads have increased across all health cadres==. [[Training on focal diseases may result in extra burdens on local health workers and divert them from other important responsibilities]] In addition, ==external funding may encourage health workers to migrate from the public sector to donor-supported NGOs, where higher wages are paid==. As a result of these concerns, the Fund has recently promoted a more comprehensive approach to service delivery in recipient countries, and has committed to provide incentives to retain health workers in the public sector. In Ethiopia, for example, Global Fund grants have been used to train and deploy ‘health extension workers’ in rural areas, who can support a wide range of essential community health services, including maternal health and case management of diarrhoea and acute respiratory infections. # Integrative Activity You are the Ministry of Health (MOH) of a government that is a member of the Global Fund. Your Prime Minister is conscious that the economic climate is affecting your country and wants to make savings.  She is thinking of cutting back on the amount of financial support available to the Fund in its next Replenishment.  It is your job to persuade her to continue to fund the Global Fund.  Formulate three reasons why funding from your government should continue. # 8.6 Conclusion Recipient countries have long expressed concerns about the financial sustainability of the Global Fund. In 2010, Global Fund donors committed far less than many were expecting or hoping for. Towards the end of 2011, the Fund announced that it had insufficient funds to finance any new projects until 2014. Clearly the Fund was in financial crisis. Since then, the financial resources of the Fund have increased substantially. However, sustainability remains a major concern – both at the global level and at country level. In Kyrgyzstan and Ukraine, for example, the dependence of health NGOs on Global Fund financial support raised concerns, as did breaks in funding – which were identified in Kyrgyzstan as a major barrier to NGOs delivering Global Fund-financed HIV/AIDS prevention services in 2007 and 2008. Nevertheless, more recent studies indicate that in Zambia, for example, the large level of funding from the Global Fund has undoubtedly been crucial. In its New Funding Model, the Global Fund has placed a stronger emphasis on improving the sustainability of its financing and better alignment with national health systems. It also aims to improve predictability of funding, country ownership, and strategic allocation of resources. The New Funding Model helped regain donor confidence and the pledges for the following replenishment rounds have further increased, despite the negative effects of the COVID-19 pandemic on national economies. This new approach, focused on building resilient and sustainable systems for health, is one of the four core objectives of the Global Fund 2017-2022 strategy (The Global Fund 2017). # 8.7 References ## 8.7.1 [[Essential readings]] [[@buseGlobalPublicPrivate2000]] Seminal text that first analysed global health public-private partnerships (GHPPPs). The article traces the changing nature of partnerships, and discusses the definitional and conceptual ambiguities surrounding the term. In this respect it is essential reading for objectives 1&2 of this session. The authors also analyse the factors which have led to the convergence of public and private actors and discuss the consequences of the trend towards partnership between UN agencies (including the World Bank) and commercial entities in the health sector. The authors provide a number of reasons why GHPPPs came about: globalization and disillusionment with the UN, and factors specific to the health sector, such as market failure in product development for orphan diseases, are examined. This is directly relevant to objective 3 of this session, where we discuss the global context, particularly globalisation. Buse and walt end the paper with a short section on the problems associated with GHPPPs – linking to objective 4 of the section. [[@buseSevenHabitsHighly2007]] This article focuses specifically on objective 4 of this session. It builds on some of the ideas in the first essential reading but is more contemporary. It provides a good ‘introduction’ to some of the problems that Global Health Partnerships (GHPs) pose for country health systems. The paper outlines contributions made by GHPs to tackling diseases of poverty. These include: getting specific health issues onto national and international agendas; mobilising funds; improving access to cost-effective health care for poor populations; and establishing international norms and standards. The paper also discusses habits that result in sub-optimal performance and negative side effects. It suggests that many GHPs are not transparent; they neglect diseases that are not suited to public-private synergy; and they lack of resources to carry out activities. Finally, the paper recommends actions that GHPs should take to improve their effectiveness. They must embrace international agreed principles of good aid practices and strive for more balanced representation of stakeholders; the private sector needs to be assessed prior to embarking on new projects and GHPs should apply standards for the selection of partners. Also, partnerships must be adequately resourced to prosper, and relationships between partners must be better managed. ## 8.7.2 [[Recommended reading]] Brugha R (2008) Global Health initiatives and public health policy. In: International Encyclopedia of Public Health (eds K Heggenbouge & SR Quah) Academic Press, San Diego, pp. 72–81. This article provides a good historical analysis of global health initiatives. It introduces the reader to the concept of a global health initiative (GHI) rather than a partnership, and traces the history of the term and practice. It also provides a succinct summary of the effect of GHIs on country health systems. So, the chapter adds to objectives 1,2 and 4 of this session. It links directly to objective 3, too, discussing GHIs in the context of Lee’s 3 dimensions of globalisation. This will be the focus of an activity in this session. Hawkes S, Buse K, Kapilashrami A (2017). Gender blind? An analysis of global public-private partnerships for health. Globalization and Health 13, 26. Available at: https://globalizationandhealth.biomedcentral.com/articles/10.1186/s12992-017-0249-1 This paper presents results from a gender analysis of several global health partnerships, showing that gender issues and strategies were neglected in the institutional functioning of most partnerships. Biesma R, Brugha R, Harmer A, Walsh A, Spicer N, Walt G (2009) The Effects of Global HIV/AIDS Initiatives on Country Health Systems: A Review of the Evidence, Health Policy and Planning, 24 (4), pp. 239-252 This is a comprehensive assessment of GHIs on country health systems. It is a systematic review of existing studies. Dodd R. and Lane C. (2010) Improving the long term sustainability of health aid: are Global Health Partnerships leaving the way? Health Policy and Planning 25: 363–371 This article provides a useful summary of the debate around sustainability of financing in development assistance for health. It suggests that Global Health Partnerships (GHPs), and their new approaches to health financing, are pioneers of a new, more sustainable way to scale up health services. This article is useful to achieve objectives 2 and 3 of this session. Best practice principles for global health partnership activities at country level: report of the working group on global health partnerships, High Level Forum on the Health MDGs, 14-15th November 2005. Bowser D et al. (2014). Global Fund investments in human resources for health: innovation and missed opportunities for health systems strengthening, Health Policy and Planning, Volume 29, Issue 8, pp 986–997, https://doi.org/10.1093/heapol/czt080 Buse K. and Tanaka S. (2011) Global Public-Private Health Partnerships: lessons learned from ten years of experience and evaluation, International Dental Journal; 61 (Suppl. 2): pp. 2–10 Richter (2004) Public–private Partnerships for Health: A trend with no alternatives? Development 47 (2) 43-48 Crawford, G. (2003). “Partnership or Power? Deconstructing the 'Partnership for Governance Reform' in Indonesia.” Third World Quarterly 24(2): 139-159. Caines K. et al (2004), Assessing the impact of global health partnerships, Department for International Development (DFID), London, UK Widdus R (2005) Public-private partnerships: An overview, Transactions of the Royal Society of Tropical Medicine and Hygiene 99S, S1—S8