Can the risk in public-private partnerships be classified ?

In the coming years, public-private partnerships (PPPs) should play an increasingly relevant role as an important alternative for financing projects and infrastructure in public services. However, especially in public health, PPPs are not always a good alternative, since they may introduce distortions in the agenda that sets health needs, favoring companies’ interests. Public agencies can benefit from collaboration with the private sector in areas where there is a lack of specialization, such as the development of research and technologies. Even in these cases, each institution’s role needs to be defined in order to avoid conflicts of interest. This can be challenging when dealing with the formulation of public and regulatory policies, on the impacts of certain policies, especially in developing countries. To engage with the private sector without compromising the integrity of government actions requires a broad discussion by public health stakeholders, for clear reasons of conflicting visions and scopes between corporations and public health. Combined with this is the need for multi-sector approaches, with a high load of financial investments in the various dimensions of policies to control the most prevalent diseases, especially chronic non-communicable diseases (NCD). This article classifies PPPs in categories in order to minimize the potential risks of conflicts of interest than can impact public health. These categories are defined as possible, possible with caveats, and impossible for involvement with certain institutions.


Introduction
The concept of inter-sector action in health is frequently used to describe partnerships between different sectors in the promotion of public health, for example to support the implementation and promotion of measures to prevent exposure to risk factors, with improvements in quality of life, through encouragement for physical activity and the development of comprehensive nutritional policies, among other measures.Such partnerships can be established within governments, involving areas traditionally unrelated to public health, such as economy and agriculture.They can also occur between sectors of society with an interest in a given theme, such as between organized civil society and the private sector ¹.
Public-private partnerships (PPPs) have emerged in a scenario where public institutions enjoy scientific credibility but lack sufficient resources and lend their name in exchange for sponsorship for the prevention and treatment of diseases, as well as for the development of research projects, thus making these partnerships an alternative for financing projects and infrastructure ².
Although there is no consensus on the definition of PPP, the U.S. National Council for Public-Private Partnership defines it as "a contractual arrangement between a public agency (federal, state or local) and a private sector entity.Through this agreement, the skills and assets of each sector (public and private) are shared in delivering a service or facility for the use of the general public" 3 .
The World Health Organization (WHO) describes a PPP as the union of a group of stakeholders who have the common objective of improving the health of populations, based on mutually agreed roles and principles 4 .Corroborating this definition, Reich highlights that PPPs should consist of three points.First, they should involve at least one for-profit private organization and one non-profit organization.Second, the partners should share efforts and benefits.Third, for PPPs in public health, a common objective for the participants should be the creation of social values to improve the health of disadvantaged populations 5 .
Public health activists and researchers have criticized the formation of PPPs on grounds that they may distort the public health agenda and favor the companies' interests.This concern is well-founded, since many problems that should be solved by public actions end up not being prioritized due to influence by nongovernmental agents that modify them according to their convenience and interests 6 .
As in many other countries, the development model adopted by the vast majority of companies working in Brazil is based on corporatism and profit-seeking, as well as investing heavy resources in advertising and marketing strategies to expand their client base, in addition to giving their products greater credibility.An example is the prizes offered by pharmaceutical and processed food companies to health professionals in order to facilitate this relationship, which often extrapolates ethical boundaries 6 .
There are companies in Brazil that promote partnerships with public institutions in the health area for the promotion of socially responsible activities like the fight against childhood cancer, the race for smoking cessation, and others.Such partnerships often display blatant contradictions.An example is the participation of companies to promote events to reduce childhood obesity and diabetes, but which actually produce ultra-processed, high-calorie, and nutritionally poor foods that constitute a risk factor for chronic non-communicable diseases 7 .
The Lancet (2013) published the results of a study by the Action Group for Chronic Non-Communicable Diseases (NCD) that discusses the rising prevalence of NCD in the world and industries that produce unhealthy commodities and products.These transnational companies are the principal parties responsible for the emergence of the NCD epidemic and profit from the increase in the consumption of their products 8 .Some classic examples include the tobacco industry, which attempted to reach voluntary agreements to avoid regulation of their products' content, as well as the regulation of advertising and marketing, in order to continue to promote a product that kills one out of two of its consumers and that will kill an estimated 8 million users by 2030 9 .The alcoholic beverages, soft drinks, and ultra-processed foods industries have used similar strategies to those of the tobacco industry to undermine cost-effective public health policies.Such corporate strategies include misleading advertising, exploiting packages to promote the product, lack of product information on potential risks to consumers, displaying the product in featured places and visibility targeted to chil-Cad.Saúde Pública 2017; 33 Sup 3:e00086316 dren and adolescents, among others 8,10 .It is increasingly common for groups of companies to lobby governments to prevent the adoption of measures to regulate products, including indirect action by shell organizations 11 .Such cases speak against the establishment of public-private partnerships or self-regulation, since according to the available scientific evidence, government intervention is the only mechanism that can avoid or reduce the harm caused by such industries.Additionally, based on the same conflicts of interest, these companies should not play any role in national or international policymaking to control NCD 8 .The same should be said of the shell groups for these companies, which should not be accepted as partners.
Observing the recent history of restrictive laws aimed at reducing exposure to risk factors, multinational industries like tobacco, alcoholic beverages, soft drinks, and ultra-processed foods have attempted to influence governments to sign voluntary agreements, based on the claim of not suffering abrupt drops in their revenue 12,13 .
The tobacco industry has frequently promoted events on citizenship and participated in forums that discuss the role of companies in maintaining natural reserves; it is a member of the UN Global Compact providing for responsible actions in the environment and human and labor rights 4 .A similar contradiction exists with the alcoholic beverages industry, which sponsors sports events and promotes advertising campaigns targeted to youth, even when their product is known to be associated with the development of diabetes, hypertension, and cancer, while its marketing strategies aim to increase social drinking and result in growing disease prevalence 15,16 .
The World Health Organizattion Framework Convention on Tobacco Control (WHO-FCTC) includes a specific article and guidelines for the convention's enforcement, aimed at dealing with interference by the tobacco industry (Article 5.3) and encouraging governments to protect public tobacco control policies from such interference 17 .
Desirable and feasible public-private partnerships do exist, however.Public agencies can benefit from collaboration with the private sector in areas where there is a lack of specialization, such as the development of research and technologies.But even in such cases, the institutions' respective roles need to be well-defined before any actual steps are taken in order to avoid conflicts of interest.This can be challenging when dealing with the formulation of public and regulatory policies, particularly concerning the impacts of given policies on developing counrries 18 .
This article discusses which public-private partnerships may be established in public health and how governments should act to safeguard themselves in case of conflicts of interest.

Methodology
This article aims to reflect on the different strategies used in the formation of PPPs.A narrative literature review was performed, consulting books, periodicals, and gray literature selected from LILACS, SciELO, PubMed, and Capes Periodicals for scientific articles and the internet for gray literature.The descriptors and respective terms used in the searches were: public-private partnerships, partnerships AND health, partnerships AND health promotion, partnerships AND prevention of chronic noncommunicable diseases, and health policies.Documents were included for analysis when published from 1998 to 2015 in English or Portuguese.The study was conducted from August 2013 to April 2016.

Discussion
According to Kraak et al. 19 , six challenges should be considered in PPPs in order to diminish the risks resulting from such partnerships in the area of public health: (i) balance between private interests and public health interests; (ii) management of conflicts of interests and biases; (iii) ensure that associations in the use of trademarks support healthy products and environments; (iv) compliance with ethical codes of conduct; (v) due diligence to assess the partnership's compatibility; and (vi) follow-up and evaluation of the partnership's results.
Cad. Saúde Pública 2017; 33 Sup 3:e00086316 Developed countries like the United Kingdom report having succeeded in negotiating targets that have an impact on the population's health, like the partnership with private companies in the food industry and the reduction in salt levels, bringing immediate benefits on blood pressure and the development of non-communicable diseases.Civil society has played an important role in this proposal, since it monitors and inspects compliance with these agreements 20,21 .
Public-private partnerships in health need to be assessed in great detail, and for this purpose the United Nations created the Standing Committee that sets rules for engagement with the private sector.The committee drafts manuals to orient interaction between government and food industries, for example, ensuring the maintenance of an open and transparent dialogue on potential conflicts of interest and guaranteeing that these issues are adequately managed 22 .
Another good example involves the guidelines on strategies that are being adopted to contain the consumption of alcoholic beverages.The guidelines propose regulation of content and volume of marketing, whether through direct or indirect advertising, in some or all media; sponsorship activities; and bans or measures to restrict access for products targeting young people 23 .

Classifying public-private partnerships
The use of PPPs in public health requires innovative solutions.Examples can be found in various countries, and as long as the rules set by government regulatory bodies are complied with, PPPs can represent additional resources for research in public health.However, the balance between gains and losses may not be clear 24 .According to the authors' analyses, public-private partnerships can be divided into possible, possible with caveats, and impossible.

Possible partnerships
An example of success in this type of partnership is the Transport, Health and Environment Pan-European Programme (THE PEP), coordinated by the WHO Regional Office for Europe, in which guidelines and practical tools were developed on the beneficial effects for health and the economy from cycling and walking.The communications pieces were developed through a systematic review of relevant studies that involved specialists with expertise and knowledge in the areas of public health, epidemiology, transportation, and economics.The tools produced by the project were user-friendly and were adopted successfully by high, medium, and low-income countries 25,26 .These projects show that the use of economic arguments to defend investments in social policies can occasionally produce clear health benefits 27 .
Another successful project involving public-private partnerships was the North Karelia Project, developed by the government of Finland in the 1960s with the aim of reducing the high rates of cardiovascular diseases in the population.Changes were proposed in the population's lifestyle and consumption, with collaboration by civil society and the private sector in the government's regulatory sectors, and also agreements with some industries, especially foods.The NCD rates dropped drastically, and this PPP is still considered a model for other countries 28 .
The UK Department of Health, in partnership with the UK Food Standards Agency, considered the guidelines of the UK Scientific Advisory Committee on Nutrition (SACN) that the population's mean salt consumption should be reduced because the average intake was 9g/day, when it should have been a maximum of 6g/day for adults and even lower for children.In order to effectively meet this recommendation, UK authorities had to work with various sectors of the foods industry including retailers, manufacturers, trade associations, industry suppliers, academia, volunteer organizations, and local authorities 20 .

Possible partnerships with caveats
PPPs can lead to positive strides for the population's current health and create innovation flows that can generate future social and financial dividends to reinforce public health in a broader way.An assessment by academia is necessary to ensure a fertile scientific discussion and to contribute to the fine-tuning of the PPPs and generate guidelines for public health 29 .
Cad. Saúde Pública 2017; 33 Sup 3:e00086316 Since profit is always a corporation's main goal, it is always necessary to focus on public health before a partnership is formed between health and an industry, where the main objective of the partnership must be to decrease the levels of harmful substances.However, it is more complex to sign a partnership with companies that are known to produce and sell unhealthy foods, such as the soft drinks, fast foods, and cookies industries, and when these partnerships lack safeguards for the improvement or reduction of harmful substances.In order for there to be a real gain for public health, with better control of NCD, it is necessary to establish commitments for the reduction or even elimination of substances that are harmful to human health and the environment 7 .
Such partnerships with safeguards include the fast foods industry, non-alcoholic beverages (especially soft drinks), and the pharmaceutical industry.As long as industry and corporate interests do not override public health interests, such partnerships can be feasible 19 .
In relation to the pharmaceutical industry, it is necessary to determine whether the partnership or sponsorship of health research influences the results, favoring the prescription of certain drugs.According to Thompson 30 , this requires assessing a set of conditions and circumstances imposed by companies and commercial establishments (conflicts of interest) that can negatively influence health professionals' conduct in relation to the primary interest (which should be the patient's well-being and treatment) and the clinical trials' validity.This can be compromised by secondary interests such as economic gain, desire for notoriety, prestige, and professional recognition.Another example of a partnership with caveats is the Special Programme for Research and Training in Tropical Diseases (TDR) of the WHO, funded by the World Bank, United Nations Children's Fund (UNICEF), United Nations Development Program (UNDP), and WHO.TDR aims to facilitate, support, and influence scientific collaboration in the fight against neglected and poverty-related tropical diseases like malaria, leishmaniasis, dengue, and tuberculosis 31 .Although the initiative is led by the public sector, TDR includes participation by the pharmaceutical industry, and this partner has been carefully monitored by the TDR Joint Coordinating Board ( JCB).The JCB thus guarantees the higher interests of protecting health through mutual respect between the participating institutions, clearly defined objectives, accountability and transparency with funding agencies and the general public, and the public sector's intellectual property rights produced by joint efforts with industry 32 .

Impossible partnerships
In public-private partnerships, as in any partnership, transparency and mutual interest are indispensable.Thus, public-private partnerships between public health and the tobacco industry, weapons industry, or alcoholic beverages industry are impossible, given the impracticality of any mutual interest between the two sectors.Besides, all attempts at establishing voluntary agreements with some of these industries have failed to produce any positive result for society; on the contrary, they have delayed the enforcement of measures to label and reduce the attractiveness and consumption of their products 8 .
Illegal tobacco trade is an international problem, and the fight against it is an indispensable component of tobacco control, since illegal trade undermines countries' health objectives by weakening the policies to increase prices and taxes.An example of an impossible partnership is the agreement signed between the International Criminal Police Organization (Interpol) and the four large transnational tobacco corporations (British American Tobacco, Imperial Tobacco Group, Japan Tobacco International, and Philip Morris International) by which Interpol uses the system for tracking and locating tobacco products called Codentify, developed by Philip Morris International.This partnership between the tobacco industry and an international authority like Interpol is not adequate for those working against illegal practices that affect health, since it includes the tobacco industry as part of the fight against illegal trade, which allows and favors industry's influence on tobacco control policies and goes against implementation of Article 5.3 of the WHO-FCTC and Article 8 of the FCTC Protocol on Illicit Trade in Tobacco Products 33 .
Table 1 summarizes the possible, possible with caveats, and impossible partnerships.

Final remarks
It is common to find companies posing as "wolves in sheep's clothing", conducting multimillion-dollar advertising campaigns to promote their unhealthy products and associating them with images of wellness, joy, and success.How to deal with companies whose main goal is profit?How to establish a "promising and healthy" relationship between industries and health professionals which often involves conflicting interests?How to deal with companies when there is a clear conflict of interest?The answer to such questions is simply to prioritize the interest of public health in protecting the population from consuming products that are harmful to health, through regulation of advertising, reduction of levels of harmful substances, or the supply of healthier foods.
It is important to consider the analysis by the WHO 18 on the principles to be adopted in order to make public-private partnerships successful, recalling that they should be applied regardless of the nature of the cause and the context, whether national or international: a) in the case of WHO, which is composed of Member States and a Secretariat, decision-making falls exclusively to the entities responsible for the agreement's political organization, that is, no non-state actor can expect to obtain privileges on the same basis as the Member States.WHO is a scientific organization and conducts its public health approaches based on scientific evidence; b) the development of norms, standards, policy decisions, and strategies should continue to be based on the systematic use of proof and should be protected from influence of any kind by veiled bias, commercial interest, or any other form of undue influence; c) transparency is what safeguards and sustains public-private relations.This principle means that the WHO makes public the nature of its relations with private initiative, and in turn that private companies with any relationship with the WHO are obliged to make public their organizational objectives, institutional structures, funding sources, and the nature of their relationship with the WHO; d) the declaration of "conflicts of interest", whether real or perceived, individual or institutional, must be adequately managed and disclosed, such that all interested parties are aware of them.
Public-private partnerships will only be successful when there is a regulatory framework that prioritizes public health.Governments and health authorities, with the available scientific knowledge on risk factors for the development of diseases, have the obligation to determine what is allowed, and companies must adapt to the regulation.Partnerships can thus be productive.

Table 1
Public-Private Partnerships according to economic sectors and feasibility.

Type of partnerships Type of companies Motivations Feasibility
Possible Sports

Unprocessed foods
Promote health with the product or its consumption does not cause harm.