Mark Petticrew London School of Hygiene and Tropical Medicine Modi Mwatsama Wellcome Trust Moderator David Kidney UK Public Health Register Ask a question by clicking QampA in the menu bar and typing in the box that appears ID: 929785
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Public-Private Partnerships: the benefits, dangers and relative effectiveness of PPPs
Mark
PetticrewLondon School of Hygiene and Tropical MedicineModi MwatsamaWellcome TrustModerator: David KidneyUK Public Health Register
Slide2Ask a question by clicking ‘Q&A’ in the menu bar and typing in the box that appears
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Slide3Evaluating PPPs: evidence from the evaluation of the Responsibility Deal and other examplesMark PetticrewFaculty of Public Health and PolicyLSHTM
@petticrewmark
Slide4Defining PartnershipPublic private partnerships are not new, and span many sectorsUsually refer to collaborations with private bodies to address particular problems or to provide resources“PPPs are long-term contracts where the private sector designs, builds, finances and operates an infrastructure project…. These include new schools, hospitals, roads, housing, prisons, and military equipment and accommodation”
https://www.gov.uk/government/collections/public-private-partnerships
Slide5PPPs in public healthEmergence of PPPs and similar ‘multistakeholder initiatives’ as a model for public health interventionsPartnerships with food industry, alcohol and other industries“A distinctive feature of these arrangements is collaboration with corporate actors that are causing or exacerbating the very problems that public health agencies are trying to solve” (Marks, 2019)
Slide6The costs and benefits of PPPs‘Governments cannot solve these problems alone’‘Industry needs to be part of the solution’‘Public officials can use PPPs to exert leverage over the private sector’Access to data and expertise“Promote understanding of the objectives of others”Usually an emphasis on convergence of interests rather than divergence
Slide7The costsPolicy substitution: “Partnership” is used by unhealthy commodity industries to undermine evidence-based policiesPartnership is used to give a “health halo” to their activitiesThese industries are not public health “partners”; they do not share our public health goals or our public health expertise.PPPs provide industry actors with additional opportunities to influence public health policy and research in ways that are most consonant with their commercial interests
Ethical harms: PPPs “…create subtle reciprocities and influence that undermine the integrity of government bodies , as well as public trust in those institutions”
Slide8What is the Public Health Responsibility Deal (RD)? Public-private partnership launched in March 2011
Voluntary agreements by businesses, universities, hospitals, government, NGOs…Stated intent was to improve public health in England Encourage organisations to act on: food, alcohol, PA, health at workFor each, the RD proposed a list of possible interventions
E.g. Labelling of alcohol containers with calorie information E.g. redesigning staff restaurant menus to include more vegetables Process: sign on to specific pledges (food, alcohol, PA, health at work)Provide a delivery plan: how will fulfil the pledge(s)? What interventions? Provide annual progress report767 signatories (Feb 2015)
Slide9“By working in partnership, public health, commercial, and voluntary organisations can agree practical actions to secure more progress, more quickly, with less cost than legislation… we shouldn’t be scared to use the reach of businesses to achieve mutually beneficial aims. Put simply, commercial organisations can reach individuals in ways that other organisations, Government included, cannot.” Andrew Lansley, then Secretary of State for Health
Slide10Slide11Example pledges
Food pledge on calorie information:
Slide12The RD evaluationAnalysed all pledges across all networks; Plausibility: Multiple systematic reviews of the evidence of the effectiveness of the underlying interventions (pledges)Qualitative Interviews with industry and non-industry participants across all networks
Collected our own independent data on alcohol labelling, a key pledge (as only industry data were available)The use of ‘additionality’ to establish the counterfactual (the extent to which we judged that a planned or completed activity could have been brought about by the RD, as opposed to an activity which would have happened anyway, or which appeared to be already happening irrespective of the RD. The counterfactual was derived from assessing organisations’ delivery plans to ascertain what actions organisations would have taken in the absence of the RD.)
Slide13Relative distribution of
all
RD interventions by typeMore about structural change More about individual changeMore effective at improving health Less effective at improving health
Slide14Corroborated by other sources of data
From key informant interviews
“I believe they wanted people to, kind of, pledge other things, and that kind of thing, but I think you end up with such a long list of pledges, and 99% of them will be what people are doing, anyway. (partner- business)”From case studies “to be honest, I think we, the pledges we took were ones we were already delivering”
Slide15Main findings of the evaluation The RD’s impact on health is likely to be very limited
The RD pledges have not proposed the most effective interventions to promote physical activity, improve diet and reduce alcohol consumption in England (=the reverse)Most RD partners appear to have committed to actions that they would have undertaken regardless of the RD.
Major issues with monitoring of implementationnot independentData not systematically collectedGradually fewer well-defined quantifiable targets
Slide16How does the alcohol industry attempt to influence marketing regulations? A systematic review (Savell et al., 2016)Strategies for undermining marketing regulation included:Forming alliances with or mobilising unions/civil society organizations/consumers/employees/the publicPolicy substitution (Developing/promoting non-regulatory initiative (generally seen to be ineffective/less effective, e.g. education programmes) -such as PPPs…an example
Slide17(Funded entirely by alcohol retailers and some alcohol producers)
Slide18“Community Alcohol Partnerships (CAP) … aim is to reduce alcohol harm in local communities from drinking by young people under 25 with a particular emphasis on preventing underage drinking.”“CAP partners vary but will typically include police, trading standards, relevant local authority departments such as public health, licensing, community engagement and youth services, schools, local charities, housing associations, resident associations and alcohol retailers/licensees.”
Slide19CAPS make major claims about their evidence base“There is an emerging body of evidence – both from the five independent evaluations commissioned by CAP and the self-evaluation reports that all schemes are required to produce – that CAP helps to reduce alcohol-related crime and disorder and the acquisition of alcohol by under-18s. In recent years we have also seen significant reductions in weekly drinking among Years 9-11 in CAP schools.”CAPs describe themselves as ‘one of the most significant alcohol-industry funded initiatives tackling underage alcohol misuse with good evidence of effectiveness’
Slide20CAPs are presented by industry as an alternative to measures of known greater effectiveness in reducing alcohol harms, both in the UK and at European level. For example, in the UK, the Coalition Government’s decision not to implement Minimum Unit Pricing of alcohol cited CAPs as an example of industry-led activities which could be used as an alternative
Slide21In this alcohol industry presentation, CAPs are described as an alternative to MUP. (Other stated alternatives include Drinkaware)
Slide22Pretty important then to know whether CAPs really are this effectiveWe tried to find all these CAP evaluations that are referred to repeatedly on the CAP website*The CAP evaluations – those which could be located - report very little data, are uncontrolled, based on small numbers and subject to seasonal biases and other fundamental flaws which makes drawing inferences highly problematic. We concluded that the purposes of CAPs are (i) ‘reputation management’ which may explain why they have an explicit focus on changing and challenging public perceptions (and focus on young women), and (ii) policy substitution…
Slide23CAPs illustrate one potential function of industry partnerships: policy substitution – substitution of ineffective self-regulatory measures for public health interventions which would have greater effectiveness
Slide24Jonathan Marks: “The views here are not premised on a Manichean view of the world that frames government, the academy, and civil society organizations as inherently good, and industry as inherently evil. On the contrary, my argument rests on the idea that there are fundamental differences between the mission, purpose, and function of public sector bodies on the one hand, and corporations and trade associations on the other”.Wiliam Blake’s The Good and Evil Angels
Slide25“When engagement with the private sector fails to contribute to the achievement of public health goals, governments should employ their regulatory and legislative powers to protect their people”.WHO NCDs Commission report 2018https://apnews.com/bdb0423fe4914be0b267a458701bc813
Slide26Characteristics of effective voluntary agreements
Targets need to be based on best evidencePledges need to be realistic but stretching, going beyond ‘business as usual’
Targets need to be measurableIncentives or sanctions related to complianceThe public, and civil society organisations needs to be involved in development and monitoring of pledges The Public Health Responsibility Deal Not most effective interventions to reduce alcohol-related harms in EnglandMost RD partners appear to have committed to actions that they would have undertaken regardless of the RD Plans most often not formulated as SMART objectivesNo clear incentives or sanctions The public was not involved Few civil society organisations involvedCan PPPs work? factors that increase the effectiveness of voluntary agreements:
The RD pledges didn’t meet criteria for effective voluntary agreements
Slide27Funding/Acknowledgements:Director: Public Health Policy Unit (NIHR PRP funded); CI, Policy Innovation Research Unit (NIHR PRP funded)NIHR School for Public Health Research at LSHTM Co-Director;SPECTRUM consortium: Funder=UKPRP;Evaluation of the English Public Health Responsibility Deal; Funder: UK Department of Health, Policy Research Programme (through PIRU);
Disclaimer: Sole responsibility for this research lies with the authors and the views expressed are not necessarily those of the Department of Health and Social Care. The DHSC played no role in the design of the study, the interpretation of the findings, the writing of the paper, or the decision to submit for publication.Acknowledgements: Cecile Knai, Nick Mays, Elizabeth Eastmure, Nick Douglas, Mary-Alison Durand
Published papers available here:https://piru.ac.uk/projects/completed-projects2/public-health-responsibility-deal-evaluation.htmlCited book: The Perils of Partnership. Jonathan H. Marks, OUP 2019
Slide28End
Slide29Slide30Slide31Public-private partnerships in public health: Lessons from a global casebookDr Modi Mwatsama, Senior Science Lead – Food Systems, Nutrition and HealthWellcome Trust Our Planet, Our Health programmeUK Public Health Network webinar on public-private partnerships15 July 2020
Slide32Presentation outlineBackground to the projectThe nutrition governance casebookCritique of institutional COI guidanceMy personal reflections
Slide33Strengthening the governance of diet and nutrition partnerships for the prevention of chronic diseases. Meeting report. April 2016
Slide34Bellagio meeting, October 201520 diverse opinion-forming stakeholders from 14 countries across six continentsIncluded and informed by:key-informant interviews with public and private sector actorscomprehensive literature review
presentations on PPP experiences from different parts of the world Critiqued institutional guidelines on COIIdentified gaps and made recommendations for action
Slide35Two major concerns for PPPs emerged:Implications for the independence, integrity, and credibility of government bodies and public health actorsImpact on public health agendas and priorities, and framing of problems and potential solutions
Slide36Major challenges around tackling COIs for PPPs identifiedLack of awareness of the issues / drawbacksLack of guidance on dealing with PPPsLimited capacity for action
Perceptions of the issue being anti-business
Slide37Presentation outlineBackground to the projectThe nutrition governance casebookCritique of institutional COI guidanceMy personal reflections
Slide38Casebook aim & objectivesIncrease awareness of the ethical & COI challenges of PPP on diet-related NCDs in research, policy and practiceAdvance debate & dialogue to strengthen governance & address COIs
https://www.idrc.ca/sites/default/files/sp/Documents%20EN/ukhf-casebook-jan18.pdf
Slide39Examples of the 12 casesCASE 1 The development of a national obesity and diabetes prevention and control strategy in Mexico: actors, actions and conflicts of interestCASE 2 Conflicting goals and weakened actions: lessons learned from the political process of
increasing sugar-sweetened beverage taxation in ChileCASE 3 Sugar-sweetened beverages
, non-communicable diseases and the limits of self-regulation in FijiCASE 5 Industry involvement in government nutrition advisory groups in Canada: a decade of inaction on trans fat and sodiumCASE 9 Public-private interaction with the alcohol industry and failures in the regulation of alcohol in SpainCASE 10 From participation to power: how the sugar-sweetened beverage industry shapes policy through (global) multi-stakeholder coalitions
Slide40Main Casebook findingFew public health actors – e.g. policy makers, researchers, and non-governmental organisations – have the tools, skills, and resources to identify and mitigate the potential pitfalls of engaging with corporate actors.
Slide41Casebook lessons (1)Raise awareness of the commercially-driven actions of corporate actors Redress actor imbalances: Increase participation of public interest actors in policy-makingDifferentiate between different private sector interests
Clarify who is compatible with representing the private sector in nutrition policy-making.
Slide42Casebook lessons (2)3. Strengthen governanceDevelop risk assessment & management tools Adopt robust procedures & structures to guide PPIsReview and revise the global health & development partnership paradigm4. Implement monitoring and research
Enhance global monitoring & understanding of the commercial determinantsReview, monitor & evaluate PPIs
Slide43Presentation outlineBackground to the projectThe nutrition governance casebookCritique of institutional COI guidanceMy summary reflections
Slide44Critique of 12 institutional guidelines on PPPsIncluded frameworks, tools and principles from the health sector (funders, NGOs, academic institutions)Examined:What areas are well comprehensively addressed?What are some ways in which guidance could be strengthened?What concepts and principles are implied, but not explicitly in the guidance? How might this influence their implication and application?
Slide45Example strengths of existing guidanceRecognise a broad range of different types of conflicts (e.g. financial and non-financial, family)Articulate PPP purpose & types
Recognise the moral jeopardy in relation to ethical, reputational, governance and relationship risksAssess the costs associated with COIs, and some categorise these on a scale
Require independent assessment of ethics & due diligence
Slide46Example weaknesses of existing guidance Lack criteria for disengagementFail to identify PPP COI risks to wider public health objectives e.g. lobbying, the effects of reciprocities
Emphasise transparency at the expense of other measures e.g. sanctions Presume PPP outcomes will be positive without assessing the probabilities
Focus on managing PPP tensions with no option to avoid PPPsFail to specify who developed the guidance
Slide47Suggested minimum good practice criteria for risk management guidelinesEthics assessments prior to entry into a partnership with corporations
On-going reviews of engagements and PPPs to assess effectivenessExit mechanisms for PPPs should form a core component of partnerships for public health.
Slide48Presentation outlineBackground to the projectThe nutrition governance casebookCritique of institutional COI guidanceMy summary reflections
Slide49Lesson / recommendationMy reflections on recent progress
Raise awareness? +ve some progress e.g. SPECTRUM / NCD Alliance collaboration
-ve widespread pandemic corporate sponsorships of healthcare sectorRedress actor imbalances: public interest in policy-making?differentiate between industry interests? who represents the private sector in public health policy?-ve remains a huge concern – especially as public health and civil society funds and capacity are impacted by the pandemicStrengthen governance +ve PHE guidance on engaging with the alcohol industry; more local level guidance?Implement monitoring & research +ve SPECTRUM / NCD Alliance initiative-ve not a mainstream issue that is addressed by funders-ve need a UK observatory to monitor systemic corporate practices and progress made
Slide50https://www.ed.ac.uk/spectrum and https://ncdalliance.org/news-events/news/help-map-unhealthy-commodity-industries-responses-to-covid-19
Please contribute!
Slide51AcknowledgementsRima Afifi, Joaquin Barnoya, Simon Barqueras, Hala
Boukerdenna, Renaud F Boulanger, Simon Capewell, Caroline
Cerney, Jeff Collin, Angela de Silva, Erica Di Ruggiero, Sharon Friel, Hala Ghattas, Fabio Gomez, Greg Hallen, Sir Trevor Hassell, Karen Hofman, Cecile Knai, Premila Kumar, Jane Landon, Zee Leung, Paul Lincoln, Tim Lobstein, Jonathan H. Marks, Rob Ralston, Sarah Viehbeck.
Slide52Thank you!@ModiMwatsama
Slide53Q&A
How do the issues raised relate to your own experiences of PPPs?
What challenges have you experienced in this area? What support do you need (if any)?What might you do differently in future?