Promoting population health with publicprivate partnerships: Where’s the evidence?

Introduction Public-private interactions have become common in the health sector. Governments, multilateral institutions and industries are applying these arrangements to address diverse health related issues. The origins and reach of the so called public-private partnerships (PPPs) have been thoroughly described at the global level [1–3] and have been supported by many authors [4]. Goal 17 of the United Nations Sustainable Development Goals for 2030 actively advocates for countries to “Encourage and promote effective public, public-private and civil society partnerships, building on the experience and resourcing strategies of partnerships” [5]. Arguments in favour of PPPs include that the immense threats to health cannot be tackled by governments alone [6]; that PPPs enrich the capacity, quality and reach of public health services [7]; that partnerships help to put health in all policies [8]; that they improve self-regulation [9]; and finally, that © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( * Correspondence: 1Department of Public Health, Universidad Miguel Hernández de Elche, Alicante, Spain 2 CIBER Epidemiology and Public Health (CIBERESP), Madrid, Spain Full list of author information is available at the end of the article Parker et al. BMC Public Health (2019) 19:1438 PPPs promote sustainable business models that allow innovation in more healthful design and content of products [10]. However, criticism has also arisen regarding PPPs in the health sector. Authors argue that alliances between public health and private sector have inherent conflicts of interest that cannot be reconciled when the products or services provided by the private partner are harmful to health [11, 12]. Collaboration in health promotion confers legitimacy and credibility on industries that produce such disease-related products and can damage the credibility of public health institutions [13]. Furthermore, public-private interactions may lead to institutional capture when companies succeed in influencing governments and multilateral institutions to undermine regulatory measures to protect population health, such as taxation [12, 14]. While many public-private interactions are used in developing, financing and providing public health infrastructure and service delivery or in providing drugs, vaccines or other products, significant criticism has arisen when it comes to agreements between governments and industries that are negatively associated with health, especially in the area of health promotion [4]. There is an important difference between health promotion and service provision in that there is limited commercial interest in health promotion initiatives. Health promotion is understood as the process of enabling people to increase control over and improve their health, covering a wide range of social and environmental initiatives to improve the adoption of healthy public policies, increase health literacy and make changes in the physical environment that ultimately make adopting healthy behaviours easier for the population. A proportion of these activities may enter in direct conflict with business models. Some authors call for precaution when entering in partnerships for health promotion with companies that market products negatively affecting health, at least while there is no evidence of their effectiveness. Moodie R et al. suggest there is no evidence that the partnership of alcohol and ultra-processed food and drink industries is safe or effective, unless driven by the threat of government regulation [15]. Galea and McKee have recommended five tests before policy-makers engage in public–private partnerships [16]. The premise is to avoid partnerships when the core product or service provided by the company is health damaging, and to ensure their role in the partnership is to aid implementation of activities and not to develop general strategy lines, which is ultimately the responsibility of public partner alone. Recognition of the potentially damaging effects of collaboration with large corporations has grown in recent years, and the Global Fund’s decision to enter into partnership with Heineken in African countries was swiftly reversed after uproar and pressure from the civil society [17–20]. Yet, the debate continues, and earlier this year, Iliff and Jha [18] argued that limiting partnerships to companies whose products have no harms would eliminate nearly all potential opportunities for collaboration, and may seriously limit progress towards achieving global health goals. Instead they suggest that global health community evaluate all potential partnerships with more clearly enunciated, established criteria. Beyond the need to establish criteria for engaging with private partners to implement health promotion programs, scientific evidence on the effectiveness of these partnerships becomes the key issue. Ideally evaluations should address whether or not the partnership is able to produce a real and durable improvement in population health. While it may be challenging to demonstrate changes using health indicators, intermediate proxy indicators established prior to carrying out the evaluation can be useful to indicate that the initiative is having the desired effect. The difficulty to evaluate public-private interactions, and the frequency of potential conflicts of interest could explain the scarcity of evaluations, particularly in health promotion [4]. So far, several evaluations have addressed public-private agreements on health services provision or have been restricted to evaluating features of the PPP related to successful f