Public-Private Partnerships and International Health Policy-making: How can public interests be safeguarded?

Full text

Public-private partnerships (PPPs) are
promoted as the innovative policy
model of the new millennium. Should
we be concerned about the rush
into closer relationships with business?
What are the effects of this policy
on the decision-making powers of
nation states and the UN system?
Will transnational corporations use
these new channels to exert more
influence in public affairs? What
safeguards are in place to protect
democratic and participatory decision-
making?
This publication summarises the findings of a review of the development
of public interest safeguards in the health arena with a focus on the World
Health Organization. It explores challenges to the establishment of an
effective system to enable WHO to deal with conflicts of interest and
other risks linked to the relationships between public and business-interest
actors. A lack of space for open discussion about the new policy paradigm
is identified as a key obstacle.
This publication makes a contribution to candid public debate. It argues
for a re-examination of safeguards of other UN institutions, such as UNICEF.
It proposes another look at such high-level arrangements as the legally-
independent global health PPPs and the UN Secretary-General’s Global
Compact initiative. It presents suggestions of ways to strengthen the UN
system’s integrity and independence to fulfil its role in international health
policy making and public interest advocacy.
Public-Private Partnerships and
International Health Policy-making
How can public interests be safeguarded?
MINISTRY FOR FOREIGN AFFAIRS OF FINLAND
Development Policy Information Unit
Judith Richter
Public-Private Partnerships and International Health Policy-making
Street address: Kanavakatu 4 a, 00160 Helsinki
Postal address: Box 176, 00161 Helsinki
Telephone: + 358 9 1605 6370 • Telefax: + 358 9 1605 6375
Exchange: + 358 9 16005 • E-mail: keoinfo@formin.fi
Homepage:http: //global.finland.fi

PUBLIC-PRIVATE
PARTNERSHIPS
AND INTERNATIONAL
HEALTH POLICY-
MAKING
How can public interests
be safeguarded?
Judith Richter

A GASPP Policy Brief based on this book: Richter, J. Public-private partnerships and
Health for All
How can WHO safeguard public interests? is available online from
www.gaspp.org/publications.
ISBN 951-724-464-9
Hakapaino Oy
Helsinki 2004
Cover Photos: Worlt Social Forum, Mumbai, 2004/Michael York, New Internationalist,
www.newint.org
Copyright: WHO/P.Virot

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING
Contents
Acknowledgements ................................................................................................... iii
About the author .................................................................................................... iv
List of acronyms and abbreviations............................................................................ v
Introduction ............................................................................................................. 1
Aims of the research project................................................................................. 1
Research methodology......................................................................................... 2
Overview ............................................................................................................. 3
1. What are public-private partnerships? ................................................................. 5
Definitions .......................................................................................................... 5
What’s new about public-private partnerships? .................................................... 7
Levels of analysis and discussion .......................................................................... 8
What is the private sector? ................................................................................... 9
2. The development of safeguards within the World Health
Organization (WHO).......................................................................................... 11
In the beginning .................................................................................................. 11
Guidelines on Interaction with Commercial Enterprises ..................................... 14
Corporate assessment procedure .......................................................................... 17
Conflict of interest guidance................................................................................ 19
Declaration of Interests for WHO Experts ................................................. 21
Training on conflicts of interest .................................................................. 24
Reasons for delay ............................................................................ 26
Two approaches .............................................................................. 27
Unwelcome advice?......................................................................... 29
An obstacle to ‘flexible’ working with industry? .............................. 31
Misunderstandings ......................................................................... 32
How conflict of interest theory may help.................................................... 33
What are conflicts of interest? ......................................................... 33
Should all conflicts of interest be avoided?...................................... 37
Dealing with perceptions of conflicts of interest ............................. 38
Strategies to avoid conflicts of interest or manage them
appropriately .................................................................................. 40
Safeguarding public interests in an era of global
public-private partnerships ......................................................................... 42
Implicit assumptions of the partnership model............................... 43
‘Partnership-building principles’ and critical scrutiny of
public-private interactions .............................................................. 44
A ‘win-win’ paradigm? .................................................................... 46
Blurring of distinctions between societal actors............................... 48
Checks and balances ................................................................................... 48
Facilitating the input of public interest NGOs .................................................... 50
i

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING
The Civil Society Initiative ......................................................................... 50
New WHO Policy for official relations with NGOs ................................... 51
Towards a review of WHO’s safeguards? ..................................................... 55
A long-standing mandate..................................................................................... 59
3. Safeguard issues in the global arena ..................................................................... 61
Legally independent global health alliances ......................................................... 61
UNICEF ............................................................................................................. 63
United Nations Guidelines and the Global Compact .......................................... 65
4. Building safeguards for public-private interactions: The wider context ................ 68
The rise of the partnership paradigm within the UN .......................................... 68
Five factors.................................................................................................. 68
The 1992 Rio de Janeiro Earth Summit ..................................................... 68
Resistance to regulation of transnational business....................................... 69
Reform of the United Nations .................................................................... 71
Talks with industry ..................................................................................... 72
Business interest in UN partnerships .......................................................... 73
The Global Compact.................................................................................. 74
The rise of the partnership paradigm within WHO ............................................ 76
Strong support from above ......................................................................... 76
A new Corporate Strategy for WHO .......................................................... 78
Shift away from Health for All ................................................................... 78
No alternatives to partnerships with business? ............................................ 81
Alternatives ................................................................................................. 82
WHO today ........................................................................................................ 82
5. Conclusion: The tasks ahead ............................................................................... 84
6. A strategy for Finland and like-minded countries ................................................ 86
Policies................................................................................................................. 86
Funding ............................................................................................................... 87
Boxes:
Box 1: WHO’s existing or envisaged measures to manage public-private
interactions and conflicts of interest as of December 2001 ......................... 16
List of annexes:
Annex 1: WHO Standards of Conduct and Financial Disclosure ............................. 88
Annex 2: WHO’s criteria for social responsibility screening ..................................... 89
Annex 3: Transparency in tobacco control process .................................................... 90
Annex 4: Declaration of Interests for WHO Experts ................................................ 91
References ................................................................................................................. 94
Index .................................................................................................. 101
ii

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING
Acknowledgments
Many people have generously contributed their thoughts, information and time to
this publication. There is not enough space to mention them all, but I hope they
know who they are and that they feel included too. My foremost thanks go to Eeva
Ollila, National Research and Development Centre for Welfare and Health, STAKES,
Helsinki, for her support and efforts in conceptualizing and carrying through this
project and for sharing her insights on global public-private partnerships in the field
of health. I am also most grateful to Minna Ilva, STAKES, for her invaluable,
professional, ever friendly research and administrative support. Thanks in addition to
STAKES as a whole for hosting this project.
I am grateful to the officials at WHO, UNICEF and the UN Global Compact who
made time in their full schedules to let me interview them and for patiently responding
to my many questions. Thanks also to colleagues and friends from UN agencies,
academia, and public interest NGOs, in particular to Lida Lhotska, International Baby
Food Action Network, Kathryn Mulvey and Larisa Ruoff, INFACT US, and Beryl
Leach, formerly Health Action International, for sharing their views and experiences.
Several others merit special mention: Marc Rodwin, Suffolk University Law School,
Boston, for digging into his treasure trove of resource material on conflicts of interest
and untiringly answering my numerous questions; Peter Utting, UNRISD, Eeva Ollila,
STAKES, and four anonymous reviewers from UN agencies, for reading through and
commenting on the paper at various stages.
This research was made possible by a grant from the Ministry of Foreign Affairs of
Finland to STAKES. I would like to express my sincere thanks to officials at the
Department of Development Cooperation for their valuable feedback during face-to-
face discussions on earlier versions of the publication and for their suggestion to publish
it as one of the reports in the Ministry’s Series Elements for Discussion. I am also
grateful to Bob Deacon, University of Sheffield, and Meri Koivusalo, STAKES, for
their proposal to publish a shortened version of this paper in the Globalism and Social
Policy Programme (GASSP) briefing paper series.
Last, but not least, profound thanks must go to Sarah Sexton for content and
English language editing. Without her patient support, this publication would not be
the same. I am grateful to all the above, but as usual the responsibility for the publication
and any shortcomings rests with myself.
iii

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING
About the author
Judith Richter, independent researcher and author, has worked on international health
issues since the mid-1980s when she taught community pharmacy in Thailand. Much
of her work has focused on exploring the interactions between UN agencies,
governments, citizen action groups and transnational corporations. She has acted as
research consultant to UNICEF, the World Health Organization, and various public
interest NGOs. Judith Richter has a multidisciplinary background. She holds a PhD
in Social Sciences, an MA in Development Studies, and a BSc in Pharmaceutical
Sciences. She has also been trained in ethics in the sciences and humanities.
iv

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING
List of acronyms and abbreviations
AAI Accelerated Access Initiative
BINGOs Business interest NGOs
CMH Commission on Macroeconomics and Health
CPSC Committee on Private Sector Collaboration
CSO Civil society organisation
CSR Corporate social responsibility
CSPI Center for Science in the Public Interest
GAIN Global Alliance for Improved Nutrition
GAVI Global Alliance for Vaccines and Immunization
GFATM Global Fund to Fight Aids, Tuberculosis and Malaria
HAI Health Action International
HFA Health for All
IARC International Agency for Research on Cancer
IBFAN International Baby Food Action Network
ICC International Chamber of Commerce
IOE International Organisation of Employers
IFM International Association of Infant Food Manufacturers
IFPMA International Federation of Pharmaceutical
Manufacturers Associations
INFACT Infant Formula Action Coalition
ISDI International Special Dietary Foods Industries (current name)
MSD Merck, Sharp & Dohme
NIEO New International Economic Order
NGO Nongovernmental organisation
PHM Peoples’ Health Movement
PINGOs Public interest NGOs
UNAIDS Joint United Nations Programme on HIV/AIDS
UNDP United Nations Development Programme
UNF UN Foundation
UNICEF United Nations Children’s Fund
UNFIP UN Fund for International Partnerships
UNFPA United Nations Population Fund
UNOSG Office of the UN Secretary-General
UNOPS United Nations Office for Project Services
UNRISD United Nations Research Institute for Social Development
TCDC Technical cooperation among developing countries
TNC Transnational corporation
WEF World Economic Forum
v

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING 1
Introduction
Public-private partnerships (PPPs) are being promoted by the World Bank, UN leaders
and number of influential governments, as the innovative policy of the New Millennium.
International civil servants and UN member states are being encouraged to engage in
one way or another in various PPPs. Undoubtedly UN institutions and states can both
benefit from interactions and collaboration with the private for-profit sector. But
concerns have been raised that an uncritical rush into closer relations with business
may erode member states’ decision-making powers, undermine the UN system, and
give transnational corporations and their trade associations additional channels by
which they can exert undue influence in public affairs and gain unfair advantage over
smaller or Southern-based companies.
Research commissioned by the Ministry of Foreign Affairs of Finland on Global
Health Related Public-Private Partnerships and the United Nations found that these
concerns were inadequately addressed in the political arena. In particular, the existing
safeguards were insufficient to protect public interests within UN-business interactions.
Managing conflicts of interests seemed to pose particular problems. The research thus
advocated “an assessment … of the safeguards in place to ensure UN integrity and [to
ensure] that public interests remain at the core of all UN activities” (Ollila 2003: 8).
The research project presented in this publication is a direct follow-up of that
recommendation.
Aims of the research project
This research project focused on Public-Private Partnerships and International Health
Policy Making: How to Ensure the Centrality of Public Interests? It had two main aims:
1. To map out the evolution of selected UN safeguards to protect public interests
and to assess their adequacy;
2. To explore the theoretical and practical problems in putting effective and adequate
conflict of interest procedures into practice.
The purpose of the research was to develop recommendations that Finland and like-
minded countries may consider making to UN agencies to facilitate the improvement
and strengthening of existing guidelines and procedures to safeguard the UN’s integrity
and independence in intergovernmental policy-making, norm-setting, and public
interest advocacy in the field of health.

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING
2
Research methodology
The project’s tasks included:
• Collecting information on existing and evolving guidelines and procedures at
WHO and other relevant UN bodies (in particular, UNICEF and the Global
Compact Office);
•Compiling a history of the debates on public-interest safeguards at WHO;
•Examining the major practical and theoretical challenges for establishing
appropriate and effective safeguards for public interests in the context of the
trend towards global public-private partnerships.
A literature review of key documents on global public-private partnerships and selected
UN guidelines for interactions with the private sector was complemented with
interviews and discussions with UN officials, academics, and representatives of public
interest NGOs, and with observations of relevant discussions within WHO’s governing
bodies (World Health Assemblies in May 2003 and 2004 and the January 2004
Executive Board Meeting).
The 25 UN officials who were interviewed from October 2003 to June 2004
included technical and programme officers with experience in interacting with the
private sector, heads of departments, executive level officials within WHO and UNICEF,
and two staff of the Global Compact Office.
The semi-structured interviews lasted from 30 minutes to two hours. The
formulation of the questions depended on the position and function of the official
being interviewed. Some questions were aimed at gaining a better understanding of
which safeguards had been developed and which not, and which ones were in the
public domain and which were considered for internal use only. If a key document
had not been made public, the interview tried to ascertain the reasons why this was so.
Interviews with technical and programme officers usually centred on two underlying
questions:
•What formal and informal safeguards have helped international civil servants to
assess whether an envisaged cooperation or funding relationship with a private
sector actor would contribute to public interests to the full?
•What mechanisms or arguments have helped UN staff members ward off industry
pressure or enabled them not to engage in arrangements and relationships that
they perceived as running counter to public interests?
The information obtained was analysed from a public interest perspective by referring
to literature in three fields: conflicts of interest in public office, medicine and science;
health and human rights; and global democratic governance.

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING 3
Overview
This publication is divided into six chapters.
The first chapter summarises some definitions of public-private partnerships that
are currently employed in UN circles. It outlines some common assumptions underlying
the public-private partnership policy model, and draws attention to the various levels
at which the issues can be analysed.
The second chapter discusses the evolution of public interest safeguards within the
World Health Organization to guide officials in their interactions with the private,
for-profit sector. The Organization’s work on developing safeguards has not been
completed even though WHO’s leadership has vigorously promoted the public-private
partnership paradigm since 1998 and despite requests from WHO’s member states
that WHO establish safeguards and share with them knowledge about the ethical
management of interactions with commercial actors.
Historical examination of WHO’s development of public interest safeguards
indicates that progress has become stalled for political reasons as much as theoretical
or technical ones. Chapter Two indicates ways in which conflict of interest theory may
prompt development to start up again and progress. At the same time, it argues that
some of the challenges posed by public-private interactions are not easily captured or
dealt with by guidelines and policies. Consequently, adequate ways of addressing these
challenges need to be sought at other levels.
This chapter on safeguards within WHO makes the observation that developing
an appropriate strategy to safeguard public interests requires attention to be paid not
just to conflict of interest theory, but also – and above all – to the understanding that
conflict of interest policies have evolved as part of intricate systems of checks and balances
in democracies, medicine and the sciences. Their development and effective
implementation within WHO should not be seen as a bothersome task, but rather as
a key prerequisite to a well functioning public institution.
The chapter argues that building up safeguards at a time when UN agencies in
general are moving towards closer interactions with business actors needs more than
formal guidelines and processes. It requires a clear recognition that the key issue is to
recover, maintain and strengthen institutional and societal environments that encourage
internal and external checks and balances to ensure that the UN agencies’ greater
proximity to money and power does not lead to consequences that are harmful to
international public interests.
Finally, this chapter highlights an important component of a broader system of
checks and balances: citizen action groups (also known as public interest NGOs) that
function as watchdog groups and thus exercise some counter-veiling power to
transnational corporations. It describes how the promise of the former WHO Director-

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING
4
General, Dr. Gro Harlem Brundtland, to increase civil society input in the global
health arena has resulted in a draft WHO’s policy governing the agency’s official relations
with NGOs that may facilitate further undue business influence in WHO decision-
making processes.
The chapter describes how the debates on this proposed Policy for Relations between
the World Health Organization and Nongovernmental Organizations led to a draft
resolution proposing an external, independent review of WHO’s mechanisms to
safeguard public interests. But given the controversies surrounding both the new policy
and the related resolution, member states assembled at the 2004 World Health Assembly
adopted neither.
Irrespective of this pending resolution, WHO already has a clear mandate to review
and update its safeguards for public interests. The main question, therefore, is how to
prevent the current political climate and pressures from weakening rather than
strengthening these mechanisms during any formal review of the Policy.
Chapter Three raises an additional aspect of the task of developing public interest
safeguards. A few examples of UN partnerships and UNICEF alliances with the private,
for-profit sector, illustrate that even the best possible safeguards within WHO could
not guarantee the centrality of public interests in the international health arena. Any
review of safeguards for public interests in international health decision-making must
also encompass a review of the guidelines and mechanisms of other relevant UN
agencies, programmes, funds, collaborative centres. It must also address some of the
political questions concerning the legally independent global health alliances and the
high-level Global Compact initiative.
The fourth chapter describes the context, particularly the push and pull factors and
shifts in frameworks of thought that brought forth the public-private partnership
paradigm. This illustrates the political sensitivities and challenges tied up with
establishing safeguards that are unambiguously based on WHO’s constitutional
mandate.
Chapter Five outlines some tasks for WHO’s Secretariat if it is to finalise its
interrupted work of establishing effective and comprehensive safeguards for WHO-
business interactions and assisting member states to avoid or manage conflicts of interests
appropriately.
In conclusion, Chapter Six makes some recommendations that policy makers in
Finland and like-minded countries may wish to adopt in pursuing the goal of updating
and strengthening safeguards at the international health policy level.

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING 5
1. What are public-private partnerships?
Literature and debates on public-private partnerships (PPPs) remain confusing for
three main reasons. First, even though public-private partnerships have been promoted
by the World Bank, the UN, a number of influential governments, businesses and
think tanks as a positive innovation for several years now, there is no one agreed-upon
definition. Second, most discussions do not distinguish between PPPs as a policy model
and actual examples of public-private partnerships and interactions that have been
undertaken.
And third, PPP is not the only term by which the interactions between the public
and the private sector under scrutiny are described. UN, academic and corporate
literature that explores PPPs uses terms such as collaboration or alliances with the
business sector; public-private joint initiatives; voluntary initiatives; multi-stakeholder
initiatives or dialogues; corporate social responsibility- or corporate citizenship
initiatives; cause-related marketing; corporate sponsorship; venture philanthropy; and
reputation- and issues-management.
Definitions
When the UN consulted its member states in 2001 on their views about the trend
towards global partnerships between the United Nations and the commercial sector,
one respondent observed that:
“There is a lack of common definitions on what partnerships mean and involve
and in how they differ from or relate to other types of relationship with the private
sector.” (UN 2001: 16)
A year later, Jane Nelson, in her book Building Partnerships that had been commissioned
by the UN Global Compact Office, an office responsible for coordinating one of the
highest-profile UN-business partnerships (see page 65 ff; 74 ff), remarked, “there has
been a tendency, within the United Nations system and elsewhere, to use the concept
of partnership very loosely to refer to almost any kind of relationship.” She suggested
the following definition:
“Partnership is a voluntary and collaborative agreement between one or more parts
of the United Nations system and non-State actors, in which all participants agree
to work together to achieve a common purpose or undertake a specific task and to

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING
6
share risks, responsibilities, resources, competencies and benefits.” (both quotes,
Nelson 2002)
A slight variation of this definition made it into the latest Report from the UN Secretary-
General on Enhanced Cooperation between the United Nations and All Relevant Partners,
in Particular the Private Sector. The Report, published in August 2003, focuses on
arrangements in which the United Nations has an interest, either as a partner or as a
partnership promoter.
“Partnerships are commonly defined as voluntary and collaborative relationships
between various parties, both State and non-State, in which all participants agree
to work together to achieve a common purpose or undertake a specific task and to
share risks, responsibilities, resources, competencies and benefits.” (UN 2003b: 4,
emphasis added)
In the health arena, the most-commonly used definition is that proposed by academics
Kent Buse and Gill Walt from the London School of Hygiene and Tropical Medicine.
They define a global public-private partnership for health (GPPPH) as:
“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 organization, so as to achieve a shared health-
creating goal on the basis of a mutually agreed division of labour.” (Buse and Walt
2000: 550)
Why did Buse and Walt define a ‘public-private partnership’ as an arrangement between
three parties rather than just two? Because their research focuses on a particular type of
global arrangement that often includes additional parties such as civil society groups,
governments and donor agencies (Buse and Walt 2002: 44).1 2 They also often involve
the creation of an intermediary body to channel funds and/or to govern the
arrangement.
1For more details, see Buse and Walt 2002: 44. For different classifications of PPPs in the health field,
see also Zammit 2003: 240.
2Another definition is that by Roy Widdus, coordinator of the the Global Forum for Health Research’s
Initiative on Public-Private Partnerships for Health. He defines public-private partnerships for health as
“arrangements that innovatively combine different skills and resources from institutions in the public
and private sectors to address persistent global health problems.” www.ippph.org, accessed 16 June
2004.

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING 7
What’s new about public-private partnerships?
Two kinds of statement are often made by PPP advocates about the novelty of global
public-private partnerships. One presents and promotes partnerships with business as
a path-breaking innovation. The other, often made in response to criticisms of PPPs,
maintains that they are not fundamentally new and points to a long history of UN-
business interactions.3
Despite their apparent contradiction, both statements have some truth to them.
The majority of public-private partnerships are not, in fact, fundamentally novel. In
the field of health, for example, they include interactions between the public and
private sector such as:
•fundraising – requesting, accepting or channelling corporate donations in cash
or in kind;
•negotiations or public tenders for lower product prices (for example, of
pharmaceuticals and vaccines);
•research collaborations;
•negotiations, consultations and discussions with corporations and their business
associations about public health matters (for instance, salt manufacturers iodizing
salt);
•co-regulatory arrangements to agree and implement ‘voluntary’ (that is, legally
non-binding) codes of conduct;
•corporate social responsibility projects (many of which are, in fact, cause-related
marketing- or other strategic sponsorship projects); and
•contracting out of public services, such as water supplies.
Subsuming such widely different issues as fundraising from transnational corporations
and privatizing water supplies under the common label of public-private partnerships
causes several problems. It obscures important distinctions between different types of
interactions and conveys a false impression about the novelty of the PPP approach.
But some newer types of public-private interactions have emerged since the PPP
paradigm was launched in the 1990s. Some analysts have suggested that these should
be viewed as ‘social experiments’ (Buse and Waxman 2001). They include global health
3The 2000 UN Guidelines on Cooperation between the United Nations and the Business Community, for
instance, open with the statement: “The business community has played an active role in the United
Nations since its inception in 1945. A number of UN organizations have a successful history of co-
operating with business. Recent political and economic changes have fostered and intensified the search
for collaborative arrangements.”

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING
8
alliances such as the Global Alliance for Vaccines and Immunizations (GAVI), the
Global Alliance for Improved Nutrition (GAIN) and the Global Fund to Fight AIDS,
Tuberculosis and Malaria (GFATM). They also include high-level policy interactions
between the UN and corporations, such as the Global Compact and business
roundtables.
The major novelty of public-private partnerships is the framework of thought
underlying the approach. As Jane Nelson suggests, a key feature distinguishing
partnerships from other interactions with the private for-profit sector is what she calls
the “shared process of decision making.” This is the critical novel characteristic of the
new policy paradigm. According to Nelson:
“In the most strategic partnerships, the partners will work together at all levels and
stages, from the design and governance of the initiative, to implementation and
evaluation.” (Nelson 2002: 47)
Indeed, the notion of shared decision-making between public and private business
actors is the single most unifying feature of public-private ‘partnerships.’4
Researcher Ann Zammit, who made an extensive review of UN-business partnerships
for the United Nations Research Institute for Social Development (UNRISD) and
the South Centre, remarks:
“The term [partnership] covers a multitude of activities and relationships, perhaps
best conceptualised as a special case of ‘close’ rather than ‘arms-length’ relationships
between government and business.” (Zammit 2003: xxv)
Levels of analysis and discussion
This publication does not discuss the pros and cons of the various definitions of public
private partnerships. (Some other key assumptions underlying the PPP paradigm are
discussed in Chapter 2.)
It is essential to be aware, however, that three levels of analysis and discussion about
PPPs are often blurred because the term ‘public-private partnership’ is used to describe:
4This is why Ollila suggests using ‘public-private interaction (PPI)’ as a general term to describe an
interaction between the UN and for-profit entities, and ‘public-private partnership (PPP)’ for those
interactions that include for-profit entities in public policy-making and setting public agendas and
priorities (Ollila 2003b: 2).

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING 9
•a policy paradigm (including the underlying framework of thought/ideology);5
•various categories of public-private partnerships or interactions (PPPs/PPIs),
such as donations of pharmaceuticals;
•specific public-private partnerships or interactions, such as the Malarone®
[malaria drug] Donation Programme.6
It is thus critical to make a theoretical distinction between these three uses of the term
‘public-private partnership’, so as to avoid the confusion that is so prevalent in debates
on the topic. For instance, institutions often respond to critical questions about the
partnership-with-business paradigm with examples of one or two specific public-private
collaborative projects that they believe have proved successful.
The term ‘public-private interactions (PPIs)’ is used throughout this study as an
overarching term to describe interactions between the public and the private sector.
The decision to opt for this more encompassing and less value-laden term was made
because a study on safeguards for interactions between intergovernmental public
institutions and commercial and business interest actors needs to focus not just on
those interactions in which UN agencies choose to engage under the banner of
partnership, but also on those interactions and joint initiatives that UN agencies may
feel pressured to engage in.
What is the private sector?
When the UN started promoting the public-private partnership paradigm in the late
1990s, it had no clear definition of ‘private sector.’ The Report of the Secretary-General
to the General Assembly 2001 on Cooperation between the United Nations and all
relevant partners, in particular the private sector defined the private sector as “all individual,
for-profit, commercial enterprises or businesses, business associations and coalitions
and corporate philanthropic foundations” (UN 2001:45-46).
Its more detailed explanations specifically excluded ‘family foundations’, such as
those established by media magnate Ted Turner or Microsoft founder Bill Gates, from
the category of corporate philanthropic foundations on the grounds that these
5In principle, given the unequal relationship between public sector actors and private sector actors
(often transnational corporations and their trade and issue-related lobby associations) and given their
fundamentally different roles and fiduciary obligations, the term ‘partnership’ in ‘public-private
partnerships’ should always be put into quotation marks. But for ease of readability, this has been done
in only a few key instances in this publication.
6For a selected list of global PPPs for health, see, for instance, Buse and Walt 2000a: 701–3.

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING
10
foundations have clearly stated “not-for-profit, public-purpose values and policies”
(UN 2001:46). It can be argued, however, that both these foundations should be
included in the private sector category when discussing public-private interactions,
particularly corporate sponsorship. First, because donations from Ted Turner’s United
Nations Foundation and the Bill and Melinda Gates Foundation are quoted in all UN
documents as a visible symbol of the supposed success of the public-private partnership
policy paradigm in mobilising previously untapped resources. Second, because both
foundations are based on a Californian style venture philanthropy model that has an
underlying business philosophy and aims to channel business thinking and operating
styles into the projects it funds. Third, in contrast to the Ford or Rockefeller foundations,
the founders of both these foundations are still active executives of companies operating
in highly competitive business areas. UN agencies will therefore have to scrutinize
carefully whether donations from these foundations might give their associated
corporations undue advantages in terms of profit or reputation enhancement.

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING 11
2. The development of safeguards
within the World Health Organization (WHO)
Each UN agency has its own history of when and how it embarked on partnerships
with the private for-profit sector, and when and how it tackled the development of
guidelines and other mechanisms to circumscribe their relationships with this sector.
This study concentrates on the development of public interest safeguards within
WHO, but also highlights some of the factors that stimulated and influenced the
policy trend within the UN system. There are two reasons for focusing on the World
Health Organization. First, safeguards at WHO are important as it is the world’s highest
authority in international public health matters. Second, WHO has probably done
more thinking that many other UN agencies on the safeguards it needs while increasing
the volume of its interactions with business interest actors. It was also one of the first
UN agencies to issue guidelines on interactions with the commercial sector that took
the partnership paradigm into account.
The histories of the development of public interest safeguards within the different
agencies are drawn from several sources, particularly key academic, WHO and UN
publications on global public-private partnerships and interviews with UN staff
members who were actively involved in developing the policy paradigm and/or
safeguards. These histories are inevitably patchy. Interviews made it clear that each
staff member has a different experience and recollection. Moreover, staff turnover
leads to a continual loss of institutional memory. It was not always possible to interview
staff members who had been key protagonists or witnesses of the beginning of the
PPP trend. Some interviewees gave divergent accounts that I was not always able to
resolve.
Despite these methodological challenges, this study managed to trace the most
significant cornerstones in the development of public interest safeguards within WHO
headquarters so as to draw out essential policy questions.
In the beginning
Like many other UN agencies, WHO has interacted with the business sector for a
long time. But when did its trajectory towards public-private partnerships start? Did
the Organization upgrade and complement its existing safeguards in step with the
changing needs that this policy shift brought about?
Academics Buse and Waxman date the beginning of the PPP trend within the
World Health Organization to 1993 when the “World Health Assembly called on

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING
12
WHO to mobilize and encourage the support of all partners in health development,
including nongovernmental organizations and institutions in the private sector, in the
implementation of national strategies for health for all” (Buse and Waxman 2001:748).
In fact, the relevant WHA Resolution 49.17 did not urge WHO’s Secretariat to follow
this path, but rather developing countries.
The Assembly’s 1993 Call for Collective Action was not asking for more partnership-
interactions with business at global level. It was primarily a call to step-up
implementation of the Global Strategy for Health for All by the Year 2000, which had
been WHO’s guiding strategy since 1978 when the Organization, together with
UNICEF, had advanced the Alma Ata Declaration on primary health care. The Call
for Collective Action placed particular emphasis on the importance of strengthening
technical cooperation among developing countries (TCDC).
The Resolution also asked the WHO Director-General to “strengthen international
technical cooperation for reinforcing and reorienting WHO programmes to mobilize
effectively political, technical and financial support for the achievement of health goals.”
It asked WHO’s richer member states to make this possible by facilitating transfer of
technology and resources to developing countries and by providing WHO with the
necessary financial resources for its work. The original Health for All framework assigned
nation states the task of determining what role business should play when the states
implemented the policy. The one sentence in the 1993 Resolution that uses the word
‘partners’ cannot be interpreted as a call for fundamental shift towards ‘partnerships’
with the private sector.7
Three years later in 1996, a WHO internal Working Group on Partnerships
examined the promotion of ‘partnerships for health’ as part of overall WHO reflections
on how to renew the Health for All Strategy for the 21st Century. A report from this
working group contained the first suggestions of principles that should govern WHO’s
interactions with the corporate sector and with NGOs (WHO 1997). These suggestions
became more publicly accessible two years later by means of an article published in a
statistical journal. The authors were the chair of the Internal Working Group, Ilona
Kickbusch, and a member of the Working Group, Jonathan Quick, who was also
Director of WHO’s Action Programme of Essential Drugs (Kickbusch and Quick
1998).
The key event in WHO’s development of safeguards, however, was undoubtedly
the election in 1998 of the Norwegian ex-premier, Gro Harlem Brundtland, as the
WHO Director-General. In her inaugural speech to the World Health Assembly, Dr.
7For more details, see WHO 1993.

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING 13
Brundtland announced a firm commitment to stronger relationships with business as
part of the Secretariat’s new outreach policy:
“The private sector has an important role to play both in technology development
and the provision of services. We need open and constructive relations with the
private sector and industry, knowing where our roles differ and where they may
complement each other. I invite industry to join in a dialogue on the key issues
facing us.” (Brundtland 1998)
On her first day in office in July 1998, Dr Brundtland enacted new Standards of Conduct
and Financial Disclosure for high-level WHO officials (see Annex 1). The aim was to
“send a clear message of high standards from the outset” of her administration (WHO
1998). But ever since, WHO’s public policy discussions and its development of
safeguards have lagged behind the partnership trend becoming institutionalised within
the Organization.
Apart from the Staff Regulations of the World Health Organization (2002) and the
Standards of Conduct for the International Civil Service of the United Nations Civil Service
Commission (2002),8 WHO’s current safeguards comprise three elements:
•Guidelines on Interaction with Commercial Enterprises to Achieve Health Outcomes;
•A corporate assessment procedure;
•Conflict of interest guidance.
Each safeguard is at a different stage of development. A coherent, comprehensive policy
framework that is transparent for outsiders has yet to emerge. The main reason that
these safeguards are incomplete – and some of them not easily available – seems to
stem from WHO’s reluctance at the highest level to see a candid and potentially
controversial debate emerge on the adequacy of the agency’s public interest safeguards.
8According to my interviews, the specific principles for financial disclosure for high-level officials
mentioned in the WHO 1998 press-release “Director-General Implements New Code of Conduct on
Financial Disclosure” were not specifically included in the staff rules. But they are being put into practice
by WHO’s Legal Office, which demands annual statements on financial interests from the top three
hierarchical layers of WHO officials.

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING
14
Guidelines on Interaction with Commercial Enterprises
WHO was initially relatively open about its elaboration of safeguards. A preliminary
version of the WHO Guidelines on Interaction with Commercial Enterprises was made
available to WHO staff and member states for comment during the summer of 1999
and to some public interest NGOs in the autumn of that year. The Chair of the Committee
of the Private Sector Division expressed the hope that these Guidelines would “contribute
to … public confidence in our dealings with the private sector while enabling innovative
and positive approaches to our cooperation and partnership” (WHO 1999b).
Several NGO respondents pointed out that the process should not just be about
providing comments on the Guidelines. They emphasized that WHO should not
interpret their doing so as implicitly endorsing or legitimizing WHO’s partnership
approach with business. They urged WHO to open up the guideline debate as part of
a broader discussion on the whole concept of UN ‘partnerships’ with commercial
enterprises (for example, IBFAN 1999, HAI 1999).9
This did not happen. In January 2001, a version of the Guidelines on Interaction
with Commercial Enterprises to Achieve Health Outcomes (as revised in November 2000)
was presented as a document “to note” at WHO’s Executive Board meeting. Many
countries voiced their grave concerns about the inadequacy of the Guidelines and the
need for a broader debate (WHO 2000c).
At this Board Meeting, some of the attending public interest NGOs10 drew the
delegates’ attention to a WHO co-sponsored seminar, the International Seminar on
Global Public-Private Partnerships for Health and Equity, held two months previously.
This seminar had categorically concluded that WHO should “step back from the
current situation and reflect upon the appropriate role of GPPPs [Global Public Private
Partnerships] in order to meet public health and equity needs.”11
They also informed Board Members that the seminar had, in addition, recommended
that WHO hold public discussions involving governments and civil society organizations,
particularly those from developing countries (CI/HAI/IBFAN 2001).
The Executive Board resolved to hold an electronic discussion on the Guidelines for
Interaction with Commercial Enterprises and their further elaboration. Yet shortly
afterwards, WHO’s Director-General decided that formal approval of the Guidelines
by the member states was not needed. She adopted the revised November 2000
Guidelines as a ‘managerial tool’ for WHO without change. The electronic debate was
9For a summary of other concerns, see for instance Beigbeder 2004: 31.
10 WHO Executive Board Meetings and the World Health Assembly are open to the public (upon
registration). NGOs in official relations with WHO can deliver statements at these meetings.
11 Reference is made to SID/WHO/ISS 2000.

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING 15
transformed into discussions during the Executive Board retreat later that year in
November 2001. Deliberations of these retreats are usually not published.12
In a note on WHO’s involvement in public-private interactions for health presented
at the Executive Board meeting in January 2002, however, the Director-General gave
a brief summary description of the discussions during the November 2001 retreat.
This note is not equivalent to minutes of discussion, but does give some indication of
the main concerns voiced by the Executive Board members at the retreat.
The note suggests that they expressed interest not only in reviewing WHO’s
experiences with public-private partnerships in health,13 but also in the Organization’s
“experiences of rejecting inappropriate suggestions for interactions.” Furthermore they:
“noted that there can be risks of, for example, focusing on the production of
inappropriate medicines, equipment or commodities. There is a need to ensure
that health systems are not distorted by donations; that costs remain under control;
and that advice is independent. There is a potential for real or perceived conflicts of
interest. Staff need to be trained to avoid these and a system of checks and balances
needs to be in place.”
They also requested the Secretariat to share with them the measures that WHO had
taken “to manage public-private interactions and avoid conflicts of interests.” Their
expressed expectation was that they could draw on such measures in their own
interactions with the private sector (WHO 2001).
The Director-General’s note listed seven measures that were in place or envisaged
to manage public-private interactions and avoid conflicts of interest (see Box 1). (As of
mid-2004, several of them are still not in place.) But doubts continued to be expressed
about the adequacy of these measures and their implementation.14
For example, Dr. Brundtland promised that the Guidelines for Interaction with
Commercial Enterprises would be updated regularly to reflect WHO’s ongoing experience.
Yet they have not been revised since 2000 even though questions have been asked, for
example, about the appropriateness of WHO’s accepting staff on temporary secondment
from commercial actors and about the adequacy of the overall decision-making
framework in relation to global health alliances that are legally independent of WHO.
12 For more information, see Ollila 2003c: 41–42, 54–55.
13 The Annex to the Director-General’s Note WHO’s Interactions with the Private Sector: Some experiences
listed some of these experiences.
14 For example, Buse and Waxman 2001; Buse and Walt 2002; Ollila 2003b; Richter 2003b; Buse
2004; Beigbeder 2004.

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING
16
Box 1:
WHO’s existing or envisaged measures to manage public-private interactions
and conflicts of interest as of December 2001
• proposals for any interaction between WHO and the private sector will need to be accompanied
by a clear statement of purpose;
• guidelines to staff on handling interactions [the Guidelines for Interactions with Commercial
Enterprises] will be updated regularly to reflect experience and will include text on recognizing
and avoiding conflict of interest. Although the guidelines are primarily for Secretariat use,
they will continue to be available on the WHO headquarters web site for the information of
Member states and the public;
• staff training modules on issues relating to private-sector interaction and conflict of interest
are being developed;
• declaration of interest forms are in use for all senior staff and WHO experts participating in
meetings. These forms require declaration of any interest which may relate to the topic of the
meeting or to the work of staff;
• a civil society initiative is in place to ensure input and engagement from nongovernmental
organizations. This will also facilitate the input of the organizations’ views on issues pertaining
to public-private interactions;
• work is progressing on a tool to help assess the good standing and practices of any companies
with whom interaction is envisaged;
• private sector interactions will be documented and reported to the Executive Board and
Health Assembly, and will be available to the public.
Source: WHO (2001), Public-private interactions for health: WHO’s involvement. Note by the Director-
General. Doc. EB109/4. 5 December

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING 17
Corporate assessment procedure
Two other safeguard elements at WHO are less well known to its member states and
the broader public: a corporate assessment procedure, and staff guidance and training
on conflicts of interests. How did these safeguards evolve? At what stage of development
are they?
Criteria for WHO’s selection and assessment of potential corporate ‘partners’ were
first outlined in 1997 by the WHO Internal Working Group on Partnerships and
publicized in a slightly revised form by Working Group members Kickbusch and
Quick.15 Work to develop an institutional corporate assessment tool gained momentum
after Dr. Brundtland became Director-General in 1998.
The 1999 preliminary Guidelines on Interaction with Commercial Enterprises
contained some guidance, albeit scattered throughout the document, on how WHO
might assess the suitability of a commercial enterprise or industry sector. It also gave
advice on how to assess specific interactions with a particular commercial enterprise or
industry sector. The document stressed the importance of avoiding conflicts of interest,
advised WHO departments to avoid any association with companies whose past
activities “might reflect poorly on the credibility of WHO,” and emphasized the need
to ensure that a commercial enterprise is a “suitable partner for WHO”16 (WHO
1999c).
Following discussions about the implicit discourse in the preliminary 1999
Guidelines, the revised 2000 Guidelines on Interaction with Commercial Enterprises to
Achieve Health Outcomes use the more neutral terms of ‘commercial enterprises’ and
‘contributor’ rather than ‘partner’. They advise a “step by step evaluation of the
commercial enterprise, including an assessment of the company and consultation with
the Office of the Legal Council” as the “best way of identifying potential areas of
conflict of interest.” The Guidelines specifically advise WHO departments to avoid
relationships with commercial enterprises “whose activities are incompatible with
WHO’s work, such as the tobacco or arms industries.”
15 Cf. points : (I) WHO policy toward the industry involved; (II) suitability of the individual company
(Kickbusch and Quick 1998:72). Some of their suggestions were taken up by WHO’s Resource
Mobilization Unit, when developing a first corporate assessment tool (unpublished document 2000).
16 The preliminary Guidelines suggested that departments should ask themselves the following questions
when developing a policy towards a specific industry:
•“Are the major products and services of the industry beneficial to health?”
•“Does the industry engage on large scale in practices which are negative to health?”
•“Does the likely public health benefit outweigh any possible harmful practices, products or
services”, p.3.

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING
18
To assess the suitability of a specific company, the Guidelines refer to evaluation
criteria that are “similar to those already in use of public agencies in assessing potential
partnerships with enterprises, including the public image, financial stability and integrity
of the company.” Moreover “commercial enterprises working with WHO will be
expected to conform to WHO public health policies in the areas of food safety, chemical
safety, ethical promotion of medicinal drug products, tobacco control and others”
(WHO 2000b, paras 9, 11, 12).
The Guidelines also provide suggestions for assessing how suitable a specific
interaction with a proposed sponsor is. For instance, they prohibit WHO from seeking
funds from enterprises “that have a direct commercial interest in the outcome of the
project toward which they would be contributing” (with the exception of clinical
trials) and advise departments to exercise caution in accepting funding from commercial
enterprises “that have even an indirect interest in the outcome of the project” (WHO
2000b, para 15 & 16).
In their 2001 assessment of WHO’s existing safeguards, Buse and Waxman expressed
the opinion that WHO did not have the internal capacity nor expertise to screen
companies “in a credible manner.” They recommended that WHO contract this task
out to a third party, such as a professional audit service, a civil society organization, or
a specially mandated UN body (Buse and Waxman 2001).17
By the time Buse and Waxman’s article was published in 2001, the process was
already underway. WHO’s Secretariat seems to have decided not to lobby for a specially
mandated UN body to make corporations more transparent to UN member states
and the general public. Instead, in 2002, WHO and four other international
organizations – the United Nations Development Programme (UNDP), the United
Nations Population Fund (UNFPA), the Office of the UN Secretary-General
(UNOSG) and the World Bank – contracted the services of an ethical investment
company, Calvert, to assist them.18
The aim of this arrangement was to ensure that the international organizations
would become better informed about the background of commercial actors before
engaging in fundraising, negotiations or collaborative projects with them. Calvert’s
social responsibility research unit establishes company profiles by screening information
against a set of common criteria.
17 For previous suggestions on how to improve of the corporate assessment process and criteria, see
Annex 2 and Waxmann 2000: 11.
18 The President and CEO of the social investment fund Calvert, Barbara Krumsiek, is on the Advisory
Board of the Global Compact.

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING 19
These criteria had been developed by the five agencies in cooperation with the UN
Fund for International Partnerships (UNFIP). Half the ‘social responsibility criteria’ –
benchmarks from the fields of human rights, environmental conduct, and labour rights
– are modelled along the lines of the Global Compact. The remaining areas are health,
social responsibility (in practice, corporate sponsorship activities) and ethical
information (including company involvement in alcohol, tobacco, arms and gambling,
company ethics and anti-corruption policies, and their research and development
(R&D) practices) (for more information, see Annex 2).
Calvert gives each company a rating based on these criteria. Calvert’s information
on the companies is considered confidential; its databank is accessible only to individuals
in the five contracting agencies.
WHO officials usually complement this information by carrying out more detailed
research on the specific circumstances of the proposed joint project and assessing
whether the enterprise has any potential hidden agendas. WHO then takes a decision
on whether or not to engage in a sponsorship relationship or other interaction with
that company. The quality of this assessment depends critically on the skills and values
of the WHO officials involved in the process.
Conflict of interest guidance
A section of the 1999 preliminary WHO Guidelines for Interaction with Commercial
Enterprises, entitled “Principles of Collaboration”, outlined the link between the
Guidelines and conflicts of interest:
“Conflict of interest is of particular concern for WHO’s work in developing public
health guidance, in setting regulatory standards and in other activities which may
affect product costs, market demand, or profitability of specific goods and services.
Such activities included norms for quality, safety, efficacy, promotion practices,
and information provision for pharmaceuticals; diagnostic and treatment guidelines
or advice which may affect the market for individual products and product categories;
chemical safety standards; and nutritional guidelines.”
“To avoid conflict of interest, real or perceived: (i) the concerned WHO Offices
and Departments must establish procedures which ensure that the establishment
of norms and standards is based on science and evidence and not on commercial
interests; and (ii) any interaction with commercial enterprises must be audited and
monitored.”

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING
20
A footnote mentioned:
“It is anticipated … to expand … the section [on Principles to Collaboration] to
deal in more detail with ethical issues arising in the establishment of collaborative
arrangements with commercial enterprises.” (WHO 1999c)
But when the WHO Director-General adopted the November 2000 Guidelines on
Interaction with Commercial Enterprises to Achieve Health Outcomes as a managerial
tool, the “Principles” had not been expanded upon. Instead they had been replaced
with a “General Considerations” section, which stated that:
“In developing relationships with commercial enterprises, WHO’s reputation and
values must be ensured. Scientific validity must not be compromised. Staff should
always consider whether a proposed relationship might involve a real or perceived
conflict of interest, either for the staff member or for the work of the Organization.
The Staff Rules and Staff Regulations (and the forthcoming ethical framework) should
guide decisions on conflict of interest relating to the personal situation of staff. The
present guidelines contain provisions relating to conflict of interest for the
Organization.” (WHO 2000b, emphasis added)
The current Guidelines contain many advices on how to assess specific interactions
with commercial actors (which are classified under: donations in cash and kind, staff
secondment, collaboration on product development, cost-recovery for WHO
evaluations, rules for meetings, ‘multi-party alliances’ and product pricing arrangements).
But nearly four years later, no comprehensive ethical framework to guide WHO’s
relationships with the commercial sector has been produced. The evolution of WHO’s
conflict of interest guidance indicates that existing conflict of interest documents have
been developed piecemeal in response either to revelations about the efforts of
corporations to exercise undue influence in international public health matters and/or
to concerns expressed about WHO’s failure to protect the integrity of public health
decision-making sufficiently. The existing documents do not seem to be the result of
a systematic, concerted strategy within the Organization to build up a coherent system
of safeguards for public-private interactions.

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING 21
Declaration of Interests for WHO Experts
The Declaration of Interests for WHO Experts, for instance, issued by the WHO Secretariat
in 2000, seems to have been developed primarily in reaction to, first, complaints about
the way WHO and its collaborating centres were handling industry participation in
their expert committees, and, second, as a side product of WHO’s efforts connected
to the proposed Framework Convention on Tobacco Control.
Pressure began soon after Gro Harlem Brundtland became WHO Director-General.
In December 1998, the Center for Science in the Public Interest (CSPI), together
with a number of scientists, drew Dr. Brundtland’s attention to problems with safeguards
and procedures at one of WHO’s collaborating centres, the International Agency for
Research on Cancer (IARC). They had documented that half the experts on a review
committee looking at the carcinogenicity of saccharin had been affiliated with food or
chemical companies or were known for their opinion that saccharin does not cause or
promote cancer. The Center and the scientists claimed that the process had been so
unscientific and industry-biased that the review appeared “rigged to exonerate
saccharin.”19
CSPI’s website documents a more than four-year debate via correspondence and
media articles demanding that WHO improve IARC’s conflict of interest safeguards
to prevent industry gaining undue influence on the grading of chemicals and foodstuffs
according to their cancer-causing effect.20
Also in December 1998, health professionals and public interest NGOs expressed
concerns about the way in which WHO had allowed a drug manufacturer to influence
new guidelines on managing high blood pressure that had been issued jointly by the
WHO and the International Society of Hypertension. A few months later in March
1999, more than 400 doctors, pharmacists and scientists from 42 countries signed a
letter to Dr. Brundtland raising the same concerns. They claimed that the new
guidelines, and the way in which the drug manufacturer exploited them, would result
in “increased use of anti-hypertensive drugs at great expense and for little benefit”
(Woodman 1999).21 22
19 To correct the bias, they suggested that WHO should demand that IARC withdraw the report and
re-evaluate saccharin’s cancer-causing potential in a new process under a new IARC director supervising
the evaluation of chemicals.
20 For more details and weblinks to the relevant correspondence and supporting documents, see the
website of the Center for Science in the Public Interest (CSPI) on its project: WHO/International
Agency for Research on Cancer, www.cspinet.org/integrity/iarc
21 For the original letter and answer of Dr. Brundtland, see www.uib.no/ifs/letter and www.uib.no/ifs/
letter/reply (accessed 6 April 2004). These signatures subsequently increased in number to nearly 900

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING
22
At the World Health Assembly in May 1999, an ad-hoc coalition of public interest
organisations and networks raised yet more questions. This time they focused on WHO’s
allowing pharmaceutical companies to gain greater influence in its decision-making
processes. Besides the hypertension management guidelines, the NGO coalition
highlighted the inappropriateness of the secondment of a Merck, Sharp and Dohme
(MSD) employee to WHO’s Tobacco Free Initiative. An internal announcement within
this pharmaceutical company called the secondment a “pioneering arrangement” and
expressed the hope that the employee could act as an “effective ambassador” within
WHO. The NGO coalition asked the Director-General to explain how the
Organization would avoid conflicts of interest when accepting funding from and
working in close partnership with the private sector. They requested that the Director-
General exclude ‘staff secondments’ from the range of collaborative arrangements
envisaged between WHO and industry (HAI et al. 1999).23
Dr. Brundtland replied in June 1999 that she did not “wish to rule out the possibility
of secondments to WHO from pharmaceutical companies.” She wrote:
“In the case of the secondment to the Tobacco Free Initiative, the company had no
interest in the area of smoking cessation, the person seconded brings to the project
a specific and needed expertise for a time limited period, and the person is specifically
excluded from involvement in activities in which the company from which she is
on secondment could have any interest. Finally, there are clear undertakings on
confidentiality, and on the person involved not seeking or accepting instructions
from anyone outside WHO, specifically the company from which she is on
secondment.” (quoted in Beigbeder 2004: 35)
Her answer failed to address two issues. First, that any person who is employed and
paid by a particular company yet working for a public institution is exposed to a
from 58 nations. As a result of these criticisms, the Guidelines for the Management of Hypertension were
revised.
22 The independent drug review bulletin, Revue Prescrire, had raised the same concerns. In December
1999, it publicized its decision to stop the process of becoming a WHO collaborating centre because of
what it considered to be the unsatisfactory response of WHO to its concerns (Prescire International
1999).
23 Health Action International (HAI) also publicised the proposal of the November 1999 WHO Expert
Committee on the Use of Essential Drugs to add nicotine patches to WHO’s Essential Drugs List. For
more details on HAI’s concerns and suggestions for addressing the problems at the time, see also HAI
2000 and Hayes 2001. For HAI’s arguments against an earlier staff secondment by the pharmaceutical
industry to the World Bank, see Beigbeder 2004: 35.

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING 23
fundamental conflict of interest. She has a divided loyalty between the for-profit
employer and the public institution. Second, to my knowledge, the work of the Merck,
Sharp and Dohme employee was not as carefully circumscribed as Dr. Brundtland’s
statement suggests. For example, she was listed as WHO staff on the list of persons
who were asked to comment on the 1999 preliminary Guidelines on Interaction with
the Commercial Enterprises.24 25
The most significant catalyst in this whole series of calls to tighten the rules for
outside experts on WHO committees was probably WHO’s own concern about the
aggressive ways in which tobacco giants tried to undermine the agency’s regulatory
efforts. In summer 1999, an internal report alerted the Director-General to the activities
of tobacco companies, which included efforts to reduce funding for tobacco control
work within UN organizations (WHO 2000e). WHO appointed a committee of
outside experts to conduct a deeper inquiry into the issue. Internal tobacco industry
documents that had become public as a result of lawsuits in the US against these
companies formed the major basis for this study.
In July 2000, the results of this inquiry were published. The report on Tobacco
Company Strategies to Undermine Tobacco Control Activities at the World Health
Organization (also known the Zeltner report after the chair of the Committee) revealed
throughout its 250 pages the ingenuity of the companies in their attempts to “contain,
neutralize and reorient” WHO’s tobacco control activities.
These activities included: funding academic centres, journalists and consultants to
act as ‘independent’ critics of WHO and to spread pro-tobacco, anti-WHO messages;
pitting other UN agencies and tobacco-growing developing countries against WHO;
planning to use food subsidiaries of tobacco companies to resist tobacco control efforts;
and attempting to influence the results of a study carried out by WHO’s collaborating
International Agency for Research on Cancer (IARC).
These activities were shocking enough. But the experts also drew attention to the
fact that WHO and other UN agencies had themselves contributed to the international
policy process becoming so vulnerable to industry influence and its counterstrategies.
24 Merck Sharp and Dohme employee Sissel Brinchmann was listed as a contributor and classified as
staff of the Tobacco Free Initiative (WHO 2000d).
25 See also Beigbeder 2004: 35, who writes: “Whatever the value of WHO’s statements, questions remain.
As an ‘ambassador’ from a pharmaceutical industry, could the seconded employee act as loyal WHO
staff member, fighting against big tobacco firms during this short period, then returning to her former
functions? Why would a pharmaceutical company agree to pay for an employee to work for WHO if it
thought it had nothing to gain from the arrangement? If a specific expertise was needed, could it not be
obtained without risk by the appointment of an independent expert, free of any commercial interests for
a short period?”

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING
24
They highlighted, in particular, WHO’s vague and confusing conflict of interest
safeguards, its lack of training programmes, and the apparent absence of clear
enforcement mechanisms (WHO 2000e: 233).
The Zeltner report contains 58 recommendations on how to prevent tobacco
companies from negatively influencing the political and scientific processes. To protect
the integrity of decision-making processes in an appropriate manner, the committee
of experts recommended that WHO and its collaborating centres improve their
institutional safeguards. They encouraged WHO to “use its leadership position to
open a Task Force discussion on the consistency and adequacy of current conflict of
interest and ethics policies within other agencies, and to promote consistent
implementation and enforcement of effective policies in all UN agencies” (WHO
2000e: 231).26
The experts further recommended that WHO promptly release this report to enable
policy-makers and the public to recognize more easily the hidden hand of the tobacco
industry and to send “a message to WHO employees at all levels that this external
threat to WHO’s integrity is real and that WHO’s conflict-of-interest and other ethical
requirements are to be taken seriously” (WHO 2000e: 228-9).
The report was, however, distributed far less widely. Nonetheless, a combination of
outside pressure and WHO consideration of the report’s findings did lead to several
positive changes: the Declaration of Interest for WHO Experts; improved staff regulations;
and a World Health Assembly Resolution on transparency in tobacco control. This
Resolution called on member states to be aware of affiliations between the tobacco
industry and members of their own delegations (WHA54.18) (see Annex 3). There
were also changes in the policy of the International Agency for Research on Cancer
(IARC) (Anello 2001: 26).
Training on conflicts of interest
The tobacco issue also gave some impetus to the development of staff training within
WHO on conflicts of interest, something that Dr. Brundtland mentioned as being
underway in her note to the 2002 Executive Board (WHO 2001: 2).
A further impetus came from some members of WHO’s Committee on Private
Sector Collaboration (CPSC), who had been troubled to find out that several WHO
officials had been trying to enter a collaborative or sponsorship relationship with certain
26 The report’s executive summary and summary recommendations provide a good overview of industry
strategies and recommended measures to counter them (WHO, 2000e: 1–18; 228–243).

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING 25
corporations in a way that clearly involved a conflict of interest according to the most
general understanding of the term.27 28
Thus in early 2001, WHO hired a consultant, Dr. Eloy Anello from Nur University
in Santa Cruz, Bolivia, to brief WHO staff on conflicts of interest. In March 2001,
Dr. Anello interviewed over 30 senior officials in WHO to identify their needs in both
avoiding and managing conflicts of interest. Three months later, he delivered his report
entitled Assessing Conflicts of Interest to WHO (Anello 2001).
The report was made available to WHO staff for a short time only. At the time of
researching this study, however, Anello’s report is not available either to WHO staff or
to the public.
When public interest NGOs asked in January 2003 why WHO had still not trained
any staff in issues relating to conflicts of interests, the response was that it was proving
difficult to find a definition of conflict of interest that ‘suited WHO’s purposes.’ What
did exist, however, was a definition for individuals in the Declaration of Interests for
WHO Experts. This stated that:
“Conflict of interest means that the expert or his/her partner (‘partner’ includes a
spouse or other person with whom s/he has a similar closer personal relationship),
or the administrative unit with which the expert has an employment relationship,
has a financial or other interest that could unduly influence the expert’s decision
with respect to the subject-matter being considered. An apparent conflict of interest
exists when an interest would not necessarily influence the expert but could result
in the expert’s objectivity being questioned by others. A potential conflict of interest
exists with an interest which any reasonable person could be uncertain whether or
not should be reported.” (WHO 2000a, emphasis added)
27 For example, a manager of the WHO Cancer Programme at the IARC had drawn up a Briefing
Document for Heinz. The section on ‘Sponsorship opportunities’ promised, in return for sponsorship of
the food TNC, “scientific and healthy living endorsement from WHO (‘naughty but nice’); removal of
trade barriers into difficult markets for Heinz products, e.g. China by riding on the back of WHO
health campaigns.” The manager described the arrangement as cost-effective for Heinz because it could
“increase market share and drive sales in … new territories without criticism of imperialism or capitalism”
(Narinesingh, n.d.). Subsequent debate within WHO led to abandoning the IARC-Heinz fundraising
project before it was put into action. For further quotes from the document, see Beigbeder 2004: 33.
28 For additional examples of industry influence and conflicts of interest in WHO’s interactions with
the commercial sector, see Beigbeder 2004: 32–36.

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING
26
The Declaration goes on to outline how WHO interprets and uses the knowledge
gained from the declarations of interests made by outside experts (see Annex 4).
But managing WHO’s interactions with the private sector so that they are in the
public interest goes far beyond ensuring the integrity of the decision-making process
in the Organization’s technical expert committees. The increased volume of global
public-private interactions and joint initiatives in the health arena and the novelty of
some of these arrangements pose many new challenges to developing an appropriate
and comprehensive ethics-based policy framework.
In 2003, momentum revived when two independent legal experts, Dr. Jean-Marc
Reymond and Dr. Edgar Philippin, who at the time were lecturing at the University of
Lausanne, Switzerland, were commissioned by WHO to develop a training module
on conflicts of interest. In June and July 2003, they held two seminars at WHO
headquarters in Geneva for WHO Executive and Programme Directors and technical
staff whose work included interacting with the private sector. No such seminars was
held at WHO’s regional offices.
The staff orientation on conflicts of interest was based on a slide show prepared by
the two independent legal experts entitled Collaborating with the Private Sector: The
Conflict of Interest Issue. As of today, no official training manual exists.
By May 2004, however, it had become uncertain as to whether any more staff
training on conflicts of interest would be held. Training will depend, in part, on whether
Dr. Jong-wook Lee, who replaced Dr. Brundtland as WHO Director-General in July
2003, and his advisers make it a priority or not.
But deeper probing into the disappearance of Anello’s report from the public sphere
point at some WHO internal stumbling blocks to issuing the promised training manual
on conflicts of interests. WHO management will have to address these stumbling
blocks if it intends to provide clear and effective institutional guidance and support
for WHO civil servants.
Reasons for delay
When Dr. Anello was commissioned by WHO to write a briefing paper on conflicts
of interest, WHO envisaged that staff training seminars would follow on from it.
Why was this plan not put into practice? Why were his report – and apparently a
subsequent training manual – taken out of the public domain? Why was there such a
delay between Dr. Brundtland’s 2001 promise to develop training materials and the
mid-2003 seminars?
Interviewees gave several answers in response to these questions. All related to Dr.
Anello’s meeting the terms of reference of his consultancy. “Dr. Anello’s work was not
considered as an acceptable basis for the proposed training” was one explanation.

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING 27
Another was that Anello had proposed an ethical definition of conflict of interest
while WHO’s legal office had wanted a legal one. A third answer was that Dr. Anello
had been asked only to ‘sensitize’ staff to conflict of interest issues, not to give any
broader advice on the adequacy of WHO’s general policies.
Two approaches
It is worthwhile examining these explanations more closely. Is the claim that Dr. Anello
did not fulfil his terms of reference sufficient explanation for WHO’s discontinuing
his work on conflict of interest training for WHO staff? Did Dr. Anello act contrary
to his terms of reference by proposing a definition of conflict of interest that was an
ethical definition rather than a legal one?
Anello’s report describes the purpose of his consultancy as follows:
“to complement the document titled ‘WHO Guidelines on working with the private
sector to achieve health outcomes’ by providing WHO staff members with a briefing
paper on the subject of conflict of interest. It is felt that the level of consciousness
and understanding of the issue of conflict of interest needs to be raised among
WHO staff members and the sharpening of skill to apply ethical reasoning in
identifying and managing conflicts of interest needs to be enhanced. In conjunction
with this paper, a briefing seminar will be given to orient staff members on the use
of a conflict of interest auditing tool designed to sharpen critical thinking and
ethical reasoning skills.” (Anello 2001: 6)
The terms of reference thus seem to have specifically requested Anello to hone the
ethical reasoning abilities of WHO staff. The terms of reference do not seem to have
specified that the suggested definition should be a legal one.
The response that Dr. Anello’s Assessing Conflict of Interest report was an inappropriate
basis for the proposed training seems weak for two reasons. First, it seems that once
Dr. Anello had delivered the report, he was contracted by WHO for a second
consultancy to devise a training manual on the management of conflicts of interest.
The second reason stems from a comparison of Anello’s work with that delivered
by the two independent legal experts, Reymond and Philippin. Both approaches start
from the same premise, namely, that the primary goal of private companies is to make
profit and that their specific activities to achieve this goal may – or may not – be
compatible with WHO’s mandate and specific objectives.
Anello then suggested that WHO’s Guidelines on Interaction with Commercial
Enterprises should be complemented with a two-tiered definition of conflict of interest:
an individual definition and an institutional one.

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING
28
An individual (or personal) conflict of interest “consists of the types of conflict of
interest that arise when a WHO staff member, in his/her relations and interactions
with a commercial enterprise or other private entity, uses his/her professional position
to influence WHO’s decisions and activities in ways that could lead directly or
indirectly to financial gain and/or other benefits for the staff member or his/her
family to the detriment of WHO and its interests.”
An organizational (or institutional) conflict of interest “consists of the types of
conflict of interest that arise when a WHO staff member or programme through
his/her actions creates a situation in which WHO enters into a collaborative
interaction with a commercial enterprise or other private entity in a manner that
puts the interests of the outside organization above WHO’s public health mission and
objectives, although the staff member as such would not gain any personal benefit.”
(Anello 2001: 17, emphasis added)
The two legal experts, Reymond and Philippin, did not come up with a definition for
institutional conflicts of interest. They decided to deal with potential risks arising
from interactions with the commercial sector by distinguishing between ‘conflict of
interests’ involving staff members and ‘potential problems’ involving the institution.
They defined personal ‘conflict of interest’ as:
“a situation in which a WHO staff member or representative finds himself [or herself ],
voluntarily or involuntarily, in a position where personal interests, obligations or past
professional positions may influence his [or her] loyalty and independence in the
objective exercise official duties.” (Reymond and Philippin 2003)
The potential problems involving the institution fell into three sub-headings. Risks to:
•the independence of WHO (for example, in standard setting);
•the image of WHO (for instance, through association with a company that has
been criticized for its unethical practices); and
•of instrumentalization of WHO (such as WHO being used to whitewash a
corporation’s tarnished image, or to endorse pharmaceutical products).
The best way to judge the quality and merits of the two approaches suggested by
Anello and the two legal consultants might have been to put their materials into the
public domain. A debate comparing the two approaches could help sharpen the thinking
of officials of WHO and its member states and of other key publics on the complexity
of the issues and might yield interesting new insights.

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING 29
My comparison with the slide series Collaborating with the Private Sector developed
by the two independent legal experts suggests that Anello’s approach is certainly not
inferior to their work, but constitutes a different approach that is also relevant to
dealing with conflicts of interest.
Unwelcome advice?
Therefore the responses from WHO interviewees about Dr. Annello’s work are not
sufficient to explain why WHO staff and the public are no longer able to access Anello’s
work to judge for themselves whether it is relevant to putting in place better public
interest safeguards for WHO’s interactions with the commercial sector.
I found Anello’s Assessing Conflicts of Interest report listed as a valuable resource in a
2001 Report from WHO’s Civil Society Initiative.29 When I asked for the document
as background literature for this study, staff members within three different WHO
departments informed me with regret that they had received instructions indicating
that this document was no longer public. I was able to obtain a copy, however, from
an individual who felt that its withdrawal conflicted with WHO’s duty of transparency
as a public institution.
The most plausible explanation for the secrecy surrounding Dr. Anello’s documents
is that at least one or two high-level WHO officials did not want Anello’s broader
advice circulated among WHO staff or made available to the public.
What advice did he give in his report? Anello suggested an ‘institutional socialization
of a code of ethics’ complemented by several measures within the WHO to enforce
such a code. His approach aimed to sharpen the ability of WHO civil servants to
detect, avoid, but, if necessary, manage conflicts of interests. His 29-page report provides
detailed suggestions as to how WHO staff might learn to understand the concept of
conflict of interest better and to minimise its occurrence. In addition, the report makes
ten recommendations on what WHO as an institution could do to protect its public
health mandate and core functions more effectively. It also outlines a conflict of interest
audit to help WHO staff check the value and potential problems of any interaction
with corporations when it is first proposed.30
Without wanting to pre-judge the details of his advice, it seems that a broader
discussion within WHO about these suggestions might have helped work on an
institutional ethics policy to progress.
29 See the Reading list of WHO/CSI 2001: 11.
30 For a more detailed summary, see Beigbeder 2004: 36–37.

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING
30
In the course of my research, I heard several staff express their concerns that WHO’s
safeguards were inadequate to prevent WHO from engaging in arrangements with the
private sector that they believed were of questionable value. Others described how
they had found it more difficult to fend off attempts by industry to gain undue business
advantages or influence since ‘partnering’ had been declared a core practice of WHO.
Anello highlighted such situations in his report:
“There is nothing inherently unethical in finding oneself facing a possible conflict
of interest. The manner in which an individual manages the perceived conflict of
interest will determine whether or not he/she has been ethical in his/her decision
making and action. Some situations of conflict of interest are due to an institution’s
failure to provide adequate orientation and training to staff members and to the lack of
clear formal rules and procedures on how to deal with conflicts of interest.” (Anello
2001: 4, emphasis added)
“WHO as institution must accept responsibility for [organizational] types of conflict
of interest … by failing to provide adequate orientation and training to staff members
to negotiate more effectively with private entities interactions that protect and
promote the interests and objectives of WHO. This is where institutional policies
related to the management of conflict of interest and ethical abuses enter the picture
… If WHO is vulnerable to this category of conflicts of interest because these
procedures and tools are not in place then the institution as a whole should be held
responsible for its own vulnerability and not just the individual employee.” (Anello
2001: 17)31
Were some high-level officials uneasy at Dr. Anello pointing to failings in WHO’s
safeguards? Scrutiny of the explanations given for the slow progress in setting up staff
training in conflict of interest, the fact that Dr. Anello’s paper is not available to WHO
31 Anello concluded with a comment on industry practices such as those pursued by the tobacco industry:
“No matter how aggressively and unethically commercial enterprises may seek to infiltrate and influence
WHO’s decision making processes, it would be to no avail, if WHO as an institution takes the necessary
measures to protect its integrity and independence and if WHO staff members are ethical and competent
in dealing with the various forms of conflict of interest that may arise in their interactions with commercial
enterprises and other private entities. Ultimately, the best protection against conflict of interest are the
WHO staff members themselves working in an organizational environment and culture that inspires
commitment to the institution and which does not tolerate situations of conflict of interest and ethical laxity”
(Anello 2001:18, emphasis added).

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING 31
staff, and Anello’s focus on institutional as well as individual responsibility for conflicts
of interest all suggest that the primary cause of WHO’s reluctance to make further
progress in this area is political.
According to Anello, all the WHO senior officials he interviewed perceived conflict
of interest as a ‘hot’ issue, particularly in light of the rapid trend towards partnerships
with the private sector. At the same time, his interviews with staff who interacted
directly with the private sector suggested that conflict of interest was a ‘taboo subject’
within the Organisation (Anello 2001: 14; 18).
What can be concluded from these observations? Why had conflict of interest
become a ‘taboo subject’ when the increased volume of interactions with the private
sector, the new partnership philosophy and the new arrangements made the overhaul
of WHO’s institutional safeguards increasingly urgent?
An obstacle to ‘flexible’ working with industry?
Some influential actors, both within and outside WHO, seem to have regarded the
very concept of conflict of interest as an obstacle to new and closer engagements with
industry. They simply wished all mention of it to go away.
One of these actors was the Commission on Macroeconomics and Health, set up
by Dr. Brundtland in 2000, which presented its recommendations to her at the end of
2001. These recommendations included reorienting WHO’s work to provide support
for global PPPs such as the Accelerated Access Initiative (AAI), the Global Alliance for
Vaccines and Immunization (GAVI) and the Global Fund to Fight Aids, Tuberculosis
and Malaria (GFTAM). (The Commission’s report, Macroeconomics and Health:
Investing in Health for Economic Development, and its chair, economist Jeffrey D. Sachs,
continue to have a powerful impact on international public health matters, both in
theory and in practice).
The Commission described concerns expressed by the WHO Executive Board and
the World Health Assembly about the potential for conflicts of interests to act as
‘constraints’ upon a “more open way of working”. It declared that “Member states
should permit the WHO Secretariat to work in more flexible partnerships with other
institutions” (CMH 2001: 100).
Nowhere did the Commission’s report explore why member states might have been
concerned about partnership interactions with powerful economic actors and donors.
The Commission itself did not regard it as problematic that many global PPPs for
health give powerful business actors decision-making roles in public health matters at
both global and national levels. The Commission itself put into practice its
encouragement of business being involved in international policy-making when it
asked Harvey Bale, the head of the research-based pharmaceutical industry association,

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING
32
IFPMA, to draw up the Commission’s background paper on international patent
legislation and access to drug issues.32
A few months after the release of the Commission’s report, Dr. Brundtland addressed
the International Federation of Pharmaceutical Manufacturers’ Association (IFPMA)
in February 2002. She appealed to industry leaders to understand the need to protect
WHO’s integrity and to ensure the “highest possible level of ethical principles and
transparency.” Clear safeguards, she said, would in the long run be beneficial to their
joint efforts. At the same time, however, Dr. Brundtland dismissed as “unfounded”
the “persistent fears – in particular among civil society organizations – that private
sector collaborations are influencing WHO’s policy focus and even the principles that
underlie our norms and standards” (Brundtland 2002b: 3). Her speech is another
example of the tension created between WHO’s desire to promote public-private
‘partnerships’ and demands that the Secretariat establish clear and effective safeguards
to protect WHO from undue industry influence.
Misunderstandings
Some of the reticence towards clearer conflict of interest policies seems to be grounded
in misunderstandings. For example, a Senior WHO Legal Officer told me that WHO
had not been able to find an official definition of conflict of interest because all the
definitions were perceived as ‘too constraining’. Another high-level official said that it
had proven extremely difficult to draw up a definition that was appropriate for WHO
as an intergovernmental agency.
But are all conflict of interest definitions really too constraining for WHO as an
intergovernmental organization? Does the constraint not emanate instead from a
widespread misunderstanding: the notion that having a conflict of interest is inherently
wrong – and that therefore all conflicts of interests must be avoided.
WHO officials in favour of more engagement with industry may have felt that any
more focus on conflict of interest would make any collaboration with industry
impossible. Others might have been concerned that any more attention to the issue
would lead to their being branded as people who have lost their personal and professional
integrity.
But neither of these concerns would in fact be realised. Certainly, rethinking and
completing the ethical basis for institutional policies governing interactions with the
private sector may result in a very different approach to that pursued today under a
partnership rubric. It would not, however, make WHO collaboration and other
32 See Boseley 2002; Horton 2002a: 1605–9.

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING 33
interactions with industry impossible. Instead, it could help staff gain a better
understanding of how to judge, justify and appropriately manage a proposed relationship
or interaction – or how to reject or abandon it. It could also give renewed impetus to
a healthy questioning of the appropriateness of shared decision-making arrangements
that decrease citizens’ control over public health matters and that are currently being
disseminated around the world as a condition of countries being allowed to participate
in many global public-private health alliances and initiatives.
How conflict of interest theory may help
The next section of this publication does not aim to draw up a detailed conflict of
interest policy for WHO to guide its interactions with transnational corporations,
their associations and their wealthy business sponsors. Instead, it aims to provide some
basic insights into theorising about conflicts of interest in the hope that this might
help resolve some misunderstandings and deadlocks.
It is followed by an exploration of issues linked to WHO’s new role as a promoter
of the public-private partnership paradigm.
What are conflicts of interest?
When talking about conflicts of interest, most people mean conflicts of interest of
individual civil servants (or health professionals) involving money or some form of
material benefits. Yet this is not the only issue involved when considering potential
risks of close UN-business interactions.
As already indicated, conflict of interest has been defined in several ways. Definitions
refer to ‘potential’, ‘apparent’ and ‘real’ (or ‘actual’) conflicts of interest, as well as ‘personal’
and ‘institutional’ ones. Any reader unfamiliar with the topic might well find it all rather
confusing. It may therefore be useful to start out with a definition that is relatively easy
to grasp. The Merriam-Webster Online Dictionary defines a conflict of interest as:
”a conflict between the private interests and the official responsibilities of a person
in a position of trust.”33
What this means in practice for citizens, civil servants and health professionals and
what should be done about it is not so easy to spell out. Theories about conflicts of
33 See www.m-w.com/cgi-bin/dictionary

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING
34
interest and regulations to tackle them will always be a history in the making. Moreover,
many issues posed by global public-private interactions are new.
According to Michael Davis, Professor of Philosophy at the Illinois Institute of
Technology and a major thinker in the field, the definitive history of the concept of
conflict of interest has yet to be written. Davis suggests that ‘conflict of interest’ started
out as a variant of what is today defined as ‘conflicting interests’. The notion of
‘conflicting interests’ usually “designated a clash between a public interest and some
private ‘beneficial’ or ‘pecuniary’ interest” (Davis 1998: 594; Davis 2001: 17).
In the late 1960s, lawyers began to connect the term ‘conflict of interest’ with
judgement. Davis thus suggests defining a conflict of interest as:
“a situation in which some interest of a person has a tendency to interfere with the
proper exercise of his [or her] judgment in another’s behalf.” (Davis 1998)
He stresses that the interest that can create a conflict of interest can be “anything that
has a tendency to bias judgement.”34 It can be of a financial nature or it can derive from
emotions or ties created by family relations, friendship, enmity and other “‘subjective
tugs on judgment.” The central issue with a conflict of interest is that it “renders one’s
judgment less reliable than normal” (Davis 1998:589, Davis and Stark 2001: 9).
Davis believes that calls for an outright ban on all conflicts of interest assume,
mistakenly, that having a conflict of interest is always wrong. He argues:
“Having a conflict of interest is not like being a thief or taking a bribe. What will be
morally right or wrong … [depends on whether and] how one resolves that problem.”
(Davis 1998: 592)35
The widespread conflation between having a conflict of interest and acting in an amoral
or illegal way often presents a major obstacle to detecting and/or disclosing conflicts
of interest. Yet admitting privately and publicly that a conflict of interest exists is a
crucial first step to dealing appropriately with any problems that such a conflict might
cause.
Marc A. Rodwin, Professor of Law at Suffolk University Law School in Boston, has
conceptualised conflicts of interest in public health. His 1993 book Medicine, Money
and Morals deals primarily with physicians’ financial conflicts of interests within the
34 For more details on what such interests can be, see Davis 2001: 9.
35 See also Davis and Stark 2001: 13.

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING 35
United States system of commercialised health care. To explain his conceptual
framework, Rodwin refers extensively to how conflicts of interest issues have been
conceptualised in other professions, and how they have been understood and handled
more generally (Rodwin 1993).36
Rodwin’s basic concept is similar to, but goes beyond, that of Michael Davis. People
have a conflict of interest, says Rodwin, “when their interests or commitments compromise
their independent judgement or their loyalty to individuals they have a duty to serve”
(Rodwin 1993: 9, emphasis added). In other words, he regards a conflict of interest as
“anything or a situation that can compromise the judgment or loyalty of an actor to the
party to which they have a defined legal or ethical obligation to serve” (Rodwin 2003).
Like other analysts in the field, Rodwin distinguishes between ‘conflicts of interest’
and ‘conflicting interests.’ People are frequently pulled in different directions, he writes,
but “unless such interests compromise known obligations, no conflict of interest exists”
(Rodwin 1993: 9, original emphasis).
Rodwin, too, found that, despite the widespread use of the term ‘conflict of interest’,
the concept has not been subject to careful theoretical analysis. He draws attention to
the ethical and legal underpinnings of the concept.
Rodwin shows that the idea of conflict of interest originated in Anglo-American
fiduciary law, particularly the law of trusts and agency. Fiduciaries are individuals that
hold property or control the legal affairs for the exclusive benefit of third parties.
Because fiduciaries have power over the affairs of others – power that can easily be
abused – and because it is difficult to monitor their conduct closely, the law holds
them to high standards. Courts have developed various rules to prevent fiduciaries
from abusing their trust.37
This fiduciary idea spread widely to government law and to the conduct of public
servants. In the late seventeenth century, English philosopher John Locke popularized
the idea that government should be a public trust and that governmental officials
should be regarded as trustees working for the benefit of the public. This idea, along
with the notion that representatives in public bodies were agents working for the
public, made it easy to import the fiduciary framework to address conflicts of interest.
36 See, in particular chapters, 1, 7 and 8.
37 Typically, courts exercise close scrutiny over the conduct of fiduciaries when they have conflicts of
interest, that is, when they have interests or commitments that conflict with their obligations to serve
their fiducies. Two main kinds of conflict occur:
1. between the fiduciaries’ personal interests and the interests of the parties they are supposed to
serve; and
2. when fiduciaries have divided loyalties between their obligations to two or more parties (Rodwin
2004).

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING
36
What does such a fiduciary concept of conflict of interest entail? In relation to
government officials and civil servants, it is usually understood that for those working
“in the government, public service – rather than profit making – is the rule” (Rodwin
1993: 180-1). Such officials and civil servants are portrayed as holding office for the
benefit of those served. The public hands over power to these officials, but in return,
they must serve the public.
The public official is seen as a fiduciary, a person who has ethical and legal obligations
to serve others. The persons served are conceptualised either as ‘beneficiaries’ or ‘fiducies.’
Although this may seem rather paternalistic to those who believe in participatory
democracy, ethics and laws governing conflicts of interest have in fact developed as an
integral part of modern democracies. The idea of fiduciary obligations in public service
has been developed because citizens cannot really check on the details of what public
officials and civil servants actually do. As Rodwin explains:
“Fiducies are seen as vulnerable because they cannot monitor fiduciaries effectively
or efficiently. This is why society [in many countries] imposes legal obligations on
fiducies to ensure that they act as expected. The law expects fiduciaries to be loyal to
their fiducies, to be scrupulously honest with them, and to act solely for their benefit.”
(Rodwin 1993:183, emphasis added)
Of common intervention strategies to address conflicts of interests, Rodwin says the
following:
“In public service, business and the legal profession, fiduciary loyalty is no longer
treated solely as an individual responsibility dependent on the good will and moral
integrity of each fiduciary. The development of policy has made public what was
once a personal, ethical issue for the fiduciary. The main concerns underlying public
policy are the preservation of fiduciary impartiality and independence, as well as
accountability.” (Rodwin 1993: 207, emphasis added)
Today, the idea of conflict of interest has spread in Anglo-American law still further to
encompass those individuals that the law does not consider fiduciaries. It has also
found its way into civil law systems that do not have the concepts of trust law or
fiduciary (Rodwin 2004).
The primary rationale behind the idea of conflict of interest policies for public
officials is to address a central problem of modern democracies: reconciling government
power with public accountability. Because public officials are supposed to act in the
interests of the public but because the public cannot easily check that they are doing

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING 37
so, Rodwin stresses that conflict of interest rules serve as an accountability mechanism,
as well as a basis for public trust in public institutions:
“One way in which we hold public officials accountable is through conflict-of-
interest laws. They prohibit public officials from being improperly influenced by
private interests or divided loyalties … Conflict of interest rules also help maintain
public confidence in government.” (Rodwin 1993: 185)38
Should all conflicts of interest be avoided?
In recent times, WHO member states have endorsed several policy documents that
call on WHO to avoid either ‘potential conflicts of interests’ or ‘all conflicts of interests’.
Yet such calls do not necessarily lead to policies most suited to addressing the relevant
problems. They could, in fact, lead to the paradoxical situation in which actors believe
that they are taking the best possible care to avoid problems arising from interacting
with commercial actors but may actually be contributing to inaction in addressing the
issue appropriately.
An initial problem is caused by the frequent use of the adjective ‘potential’. WHO’s
Declaration of Interest for WHO Experts, for instance, asks external scientists to declare
whether they know of any ‘potential conflict of interest’ that could prevent them from
serving in a public-interest centred manner on a WHO technical committees. Indeed,
much of the conflict of interest literature itself distinguishes between potential and
actual conflicts of interest.
Rodwin finds this distinction unhelpful from a legal perspective and suggests
discarding it altogether. Instead, he opts for a distinction between:
•a conflict of interest (rather than a ‘potential’ conflict of interest); and
•a breach of [ethical or legal] obligation.39
Conflicts of interest are not acts, he says. They are situations that increase the risk of
fiduciaries, consciously or otherwise, making judgements and/or acting in ways that
are not in the best interest of their fiducies.
Rodwin stresses that there is nothing morally wrong about having a conflict of
interest. He does argue, however, that calling these situations ‘potential’ conflicts of
interest belittles their risks.
38 For a summary of US conflict of interest rules for government officials, see logo Clark 2001.
39 Thus, Rodwin calls ‘conflict of interest’ what others may call ‘potential conflict of interest’. He calls
‘breach of obligation’ (that is, actual acts of disloyal behaviour) what others call ‘actual conflict of interest’.

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING
38
From a legal perspective, conflicts of interest are problematic because “they have
the capacity to cause harm – harm must not have occurred.” It is this risk – the potential
of conflict of interest situations to cause harm – that has been the driving force behind
societal demands for effective safeguards (Rodwin 1993: 9).
Taking conflicts of interest seriously does not therefore mean that all conflicts of
interests can or should be avoided. Most interactions with powerful economic actors
generate conflicts of interest. Whether or not one avoids a specific conflict of interest
or how one manages it depends on a whole range of considerations. These include
weighing up the risks posed by the proposed activity or relationship against its potential
social value, and linking this risk-benefit assessment to a clear ethical framework – in
WHO’s case to a framework that treats health as an issue of human rights and social
justice.40
Taking these considerations into account would lead to a better way of encouraging
meaningful and effective action in what Rodwin calls ‘coping with’ conflicts of interest
by demanding that institutions and individuals “avoid conflicts of interest or manage
them appropriately.”
Dealing with perceptions of conflicts of interest
Before exploring what such policies and measures might involve, it is useful to clarify
another commonly used phrase used to describe a conflict of interest, namely ‘perceived’
or ‘apparent’.
Once again, this term can easily lead to confusion – as do most dictionary meanings
given for the word ‘apparent.’ Based on the primary meaning of the word, many
people might understand an ‘apparent’ conflict of interest to mean a situation that is
“open to view”, that is “clear or manifest to the understanding”. Others, however, may
understand it according to its secondary meaning, as something that is “manifest to
the senses or mind as real or true on the basis of evidence [but] that may or may not be
factually valid”41 (emphasis added).
Davis contends that the adjective ‘apparent’ or phrase ‘merely apparent’ is overused
when referring to instances of conflicts of interest. He says that the commonly-held
40 For more information on how to weigh the risks against potential social benefits, see Rodwin 1993:
10, 222. A thorough risk assessment is an indispensable first step. But “the risk posed by a conflict of
interest is only one part of the equation. It is important to know the potential benefits from the activities
that may be subject to regulation. As the social value of activities increases it makes sense to bear greater
risk from conflicts of interest. And for activities that have little social value, society may want to curb
conflicts of interest that create even small levels of risk” (Rodwin 1993: 224).
41 Merriam-Webster Online Dictionary. www.m-w.com/cgi-bin/dictionary, accessed April 2004.

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING 39
view is that a conflict of interest is merely apparent “if, and only if, [a person] does not
have the conflict of interest … but someone other … is justified in concluding (however
tentatively) that the person has a conflict of interest.” He is categorical in his objection
to this view: “Apparent conflicts of interest (strictly speaking) are no more conflicts of
interest than stage money is money” (Davis 2001: 18).
From this perspective, it is simple to address an ‘apparent’ conflict of interest. “It is
resolved by making available enough information to show there is no actual … conflict
of interest” (Davis 2001: 18). This should be done as soon as possible, believes Davis.
If the information made available does not persuade the public, however, then the
‘apparent’ conflict of interest may well be a real conflict that should be dealt with all
the more urgently.
Other analysts see the situation as more complicated. The idea of having rules to
address the ‘appearance of conflict of interest’ or an ‘apparent conflict of interest’ has
been used most frequently in US federal law to govern conflicts of interest that civil
servants might face. There are two reasons for legislating against even the appearance
of a conflict of interest. First, given the prevalent confusion over what constitutes a
conflict of interest, over-inclusive legislation was intended to demonstrate commitment
to a high legal standard. Second, the legislation aimed to address the public’s perception
of conflicts of interest in order to ensure that governments enjoy public trust (Rodwin
2004).42
The phrase ‘apparent conflict of interest’ thus has a range of connotations. As a
result, several legal experts regard it as an unworkable subjective standard. They believe
that civil servants should not be penalised simply for the appearance of a conflict of
interest. Should, then, this term be used at all?
In examining and clarifying interactions between WHO civil servants and private
sector actors, I believe it is critical to take seriously apparent, in the sense of ‘perceived’,
conflicts of interest. This is because of the secondary function of conflict of interest
policies: to maintain public trust.
As political scientists and public relations professionals know only too well, trust is
the fundamental basis of legitimacy for any institution. If people feel that a public
official, health professional or scientist with whom they are in a fiduciary relationship
is not acting in their interest, they are likely to lose their trust not only in that person,
but possibly also in his or her profession and the institution to which s/he is attached.
42 Andrew Stark’s book Conflict of interest in American public life discusses the ambiguities of the
‘appearance of official impropriety’ (in contrast to ‘real official impropriety’) in the actions of civil
servants. The phrase ‘appearance of official impropriety’ refers either to the perception that a situation
“looks like the official did something wrong,” or that “the official did something that looks wrong”. For
more information, see Stark 2000: 208 ff.

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING
40
But the challenge for WHO and other UN agencies is not to set up intricate systems
to prevent individual civil servants from having ‘apparent’ conflicts of interest. The
main conclusion drawn from theoretical thinking on apparent conflicts of interests is
that no public institution should risk losing public trust by neglecting to address people’s
and the media’s perceptions of conflicts of interest. A system to address this should be
put in place as a matter of priority.
Strategies to avoid conflicts of interest or manage them appropriately
Setting up detailed and effective conflict of interest measures is a challenge for any
institution. Yet it is a challenge that has to be faced head on. The term ‘conflict of
interest’ has become a familiar one to many citizens in the context of relationships
between the public and the for-profit sector. How did this term become so well known?
Davis and his colleague, Andrew Stark, believe that:
“The best explanation now available for the recent rise of the concept seems to be
the replacement of enduring personal relationships … by the brief encounters
characteristic of the free market, big city, and big business. We are now much more
dependent on the judgement of others, much less able to evaluate their judgement,
decision by decision, and indeed generally know much less about those individuals
than we would have even fifty years ago.” (Davis and Stark 2001: 17)
Political scientists may have a slightly different explanation for increased interest in
the issue. The history of conflicts of interest encountered in public life shows that
meaningful measures to address the problem have often been instituted only after
public concerns have been voiced about gross abuses on the part of those holding
public office. In the US and the UK, for example, the history began when concerns
were raised about corrupt public officials. Efforts to regulate bribery and corruption
evolved into more complex conflict of interest policies when it became clear that hidden
payments were not the only way in which powerful economic actors tried to influence
public officials or the decision-making processes in public institutions. Other avenues
include honoraries for consultancies and public presentations, and a whole gamut of
donations, sponsorships and gifts as well as the implicit or explicit promise of a highly
paid private sector job once the public official leaves office.43
43 For more details of this history, see, for example, Williams 1985: 12–16.

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING 41
In the biomedical field, there has long been a debate about how to ensure the
integrity, independence and loyalty of physicians, researchers, medical journals and
drug regulators to their respective fiducies given that they all now operate in a medical-
industrial complex.44
As previously stated, there are two overall reasons for enacting conflict of interest
measures: to ensure accountability and to maintain trust. Ensuring accountability has
three further important dimensions: prevention, monitoring and remedial action.
Conflict of interest policies and laws have primarily evolved as preventive measures.
Well-defined conflict of interest policies aim to address the risks caused by conflicts of
interest and to help civil servants know and recognise the limits of their discretionary
decision-making powers. They help monitor what is actually going on. And finally,
conflict of interest policies and laws also have a remedial function. They help to redress
and compensate for wrongs. If civil servants overstep the boundaries, they can be held
accountable for breaches of defined obligations.
How can institutional and public policies be put in place to deal appropriately with
conflicts of interest? Three basic strategies underlie comprehensive conflict of interest
policies:
1. Prevention (protection of fiducies by prophylactic measures)
Disclosing conflicts of interest and prohibiting fiduciaries from entering into a
situation or relationship in which serious conflicts of interest occur (for instance,
restricting government officials from working with business for a limited period
after they have left public office).
2. Supervision through regulation
Reducing discretionary decision-making powers.
3. Sanctions and restitution
Providing remedies if fiduciaries abuse their trust or harm fiducies (Rodwin 1993:
207–8).45
44 This term was coined by US intellectual Barbara Ehrenreich in 1970 (Rodwin 1993: 13).
45 Many policy makers and health professionals are not comfortable with more public regulation of
conflicts of interest. They advocate disclosure of conflicts of interest as the alternative. But there are
limits to disclosure. Experience shows that disclosure can help to address conflicts of interest only if it is
part of a coordinated policy that: (1) “sets high standards of ethical conduct; (2) clearly delineates the
permissible from the unacceptable; (3) develops institutions to monitor behaviour; and (4) imposes
meaningful sanctions to ensure compliance” (Rodwin 1993: 219).

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING
42
In sum, conflicts of interest that professionals might face are tackled by means of three
regulatory approaches:
1. Prohibiting certain kinds of activities;
2. Regulating and monitoring conduct;
3. Providing penalties for improper conduct (Rodwin 1993: 225).
A fourth indispensable component of an institutional conflict of interest policy is a
well-articulated provision for institutional public disclosure to allow for independent,
public oversight. In WHO’s case, this provision should include making available
information that would allow WHO’s member states, public interest groups and the
media to reinforce the work of those who regulate within the UN agency the conflicts
of interest that are generated by the various public-private interactions and joint
initiatives.46
It is essential that intergovernmental public institutions are transparent and open
to public inquiry. This would allow the public to judge for themselves whether or not
the institution and its employees are acting in the best public interest. It would also go
a long way towards maintaining people’s trust in UN agencies as it would demonstrate
that the agencies have nothing to hide. Transparency and openness may also help
dissipate the widespread and growing perception that the increase in the volume and
closeness of the interactions between UN agencies and private sector actors in recent
years has increased the number of unacceptable and unchallenged conflicts of interest.
WHO’s Secretariat can demonstrate that it takes these public perceptions seriously by:
1. clarifying and widely publicising its institutional policies for its interactions with
commercial actors and its measures to safeguard public interests (including its
current ethical reference framework and conflict of interest rules and procedures);
and
2. setting up channels to investigate and respond quickly and openly to any
allegation of a conflict of interest.
Safeguarding public interests in an era of global public-private partnerships
The academic and theoretical literature on conflict of interest deals at length with
personal conflicts of interest, but is far less conclusive about issues that go beyond the
individual.
For instance, how useful is it to focus on holding individuals – in WHO’s case,
international civil servants – accountable by means of conflict of interest rules (except
46 See also Rodwin 1993: 189–189, 218.

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING 43
for higher-level officials) when their institution may be so enmeshed with for-profit
interests that it restricts the individual’s freedom of decision-making? Should such
problems be dealt with by focussing on the development of policies addressing
‘institutional conflicts of interest’? Or should they be dealt with from different, possibly
broader, value-based political perspective?
For example, researchers in the medical field are usually held to both unspoken and
to formulated codes of ethics to guarantee the scientific integrity of their research and
to ensure that the resulting knowledge is disseminated to other research institutions
and the public. Some countries have instituted a whole range of conflict of interest
and other rules to protect the integrity of medical research.
Tufts University professor Sheldon Krimsky has analysed changes in the United
States that have occurred in the past two decades because of the rise of the
‘entrepreneurial university’ and of government incentives for university-industry
partnerships. Krimsky’s research raises issues that can no longer be prevented or managed
by existing conflict of interest regulations.
Among the adverse effects of these changes – effects that are frequently overlooked
– are the erosion of academic or research ethics, the replacement of openness by secrecy,
and an unprecedented rise in conflicts of interest such that most researchers now accept
conflicts of interest as the norm rather than as an exception to be justified.
Krimsky draws attention to the inestimable cost for society caused by the production
of science in the private interest: a loss of funding and opportunity for ‘public-interest
science’, which includes scientific research on the risks and problems caused by
environmental pollutants and on the harmful side-effects of pharmaceutical drugs
(Krimsky 2003).
What particular problems have been created by WHO’s embrace of the public-
private partnership paradigm? What are some possible solutions to these problems?
Implicit assumptions of the partnership model
The consequences of UN agencies’ pursuit of the public-private partnership paradigm
have not only been an increase in relationships between the agencies and the private
sector, many of which have existed for some time. The framework of thought underlying
the partnership paradigm has also encompassed demands for a profound restructuring
of the way in which public and other ‘partners’ are meant to interact with the private
sector.
One of the key features of these newer partnerships is the ‘shared process of decision-
making’. This could well mean that conflicts of interest are built into the very design
of public-private ‘partnerships’.

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING
44
Other implicit key assumptions underlying the current PPP paradigm are that:
•interactions with business actors should be based from the outset on ‘trust’;
•they should aim at ‘mutual benefits’;
•public-private ‘partnerships’ represent a ‘win-win’ situation (or even ‘win-win-
win’ in the case of tri-sector ‘multi-stakeholder’ interactions); and
•this policy paradigm is the policy innovation of the new Millennium – or is
simply a necessity because there is no alternative.
‘Partnership-building principles’ and critical scrutiny of public-private interactions
An uncritical approach to partnerships with the commercial sector was reflected in the
1999 preliminary WHO Guidelines for Interaction with Commercial Enterprises, which
included some of these underlying assumptions. For instance, the introductory section
outlining the purpose of the Guidelines stated that “WHO must increasingly see its
role as one of harnessing support from among a variety of players.” It stated that
WHO “needs to create sound partnerships with public bodies, civil society and
commercial enterprises to make health everybody’s business.”
The preliminary Guidelines’ objective was not just ”to guide the relationship between
commercial enterprises and WHO” but also to “provide an innovative and positive
approach to cooperation and partnership with the commercial sector.”
They reiterated the need to maintain WHO’s position as an impartial holder of
health values and scientific validity, but stressed at the same time ‘general principles of
partnership-building’, which the document identified as “mutual respect, trust,
transparency, and shared benefit” (WHO 1999: 2, emphasis added).
The section describing the purpose of the 1999 Guidelines came in for heavy
criticism when they were reviewed by WHO member states and public interest NGOs.47
The core of the criticisms was that the Guidelines contained value-laden statements
about ‘partnerships’ and that the principles of partnership building would interfere
with those values and attitudes that are essential for weighing up the benefits of a
proposed interaction with a commercial actor against its risks and costs. Public interest
networks and organisations whose work includes monitoring activities of transnational
corporations have repeatedly asked that WHO refrain from using the term partnership
for interactions with the commercial sector. For example, the International Baby Food
Action Network stated during the Guideline debate:
47 For a summary of some NGO comments on the Guidelines, see, for example, Richter 2003: 11–14.
For the WHO summary, see WHO 2000d.

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING 45
“IBFAN recommends replacing the word ‘partnership’ with ‘interaction’ wherever
references are made to WHO and commercial enterprises. The ‘partnership’ discourse
anthromorphises corporations and risks blunting the critical faculties which are
essential for the assessment of the potential pitfalls of a too close and trusting
interaction. ‘Caution’ and healthy distrust seem to be the appropriate attitude for
dealing with commercial enterprises, many of which are currently involved in a
public relations exercise aiming to represent themselves as ‘responsible corporate
citizens’ who should be allowed to operate with a minimum of outside interference
or regulation.” (IBFAN 1999: 3)
As far as the role of international civil servants in these partnerships is concerned, the
criticisms can be summarised as follows:
•‘respect’ cannot simply be given (or requested or ‘built’) – it has to be earned;
•unquestioning ‘trust’ risks interfering with the spirit of caution and scepticism
needed for a proper evaluation of a proposed interaction;
•‘shared (or mutual) benefits’ are an inappropriate standard by which to assess
the benefits of a particular public-private interaction. The duty of public servants
is to ensure that any proposed arrangement benefits to the full the public that
WHO is meant to serve. (There is no need, moreover, for civil servants to ensure
that the private sector party gains benefits. The managerial, operational and
even public relations staff of the company, business association or foundation
involved will assume this task.)
WHO’s Secretariat took these criticisms on board when it revised the Guidelines. The
Guidelines on Interaction with Commercial Enterprises to Achieve Health Outcomes largely
replaced the term ‘partnership’ by less value-laden descriptions such as ‘interactions’
and ‘alliances’. The principles of partnership building were removed, and the statement
of purpose now simply says:
“These guidelines are intended primarily to help WHO staff interact appropriately
with commercial enterprises in order to achieve positive outcomes for health.”
The principle of transparency was not explicitly retained in the revised Guidelines.
But the statement of purpose declares that the Guidelines for Interaction with Commercial
Enterprises will be posted on WHO’s website (WHO 2000b: 2), a first practical step
towards transparency.
Even though the revised Guidelines took into account criticisms of the underlying
problematic assumptions of the partnership paradigm, the overall approach of WHO
as an organization has not really changed. Many of the assumptions underlying the

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING
46
partnership approach continue to prevail, in particular at the higher staff levels of the
Organization (see Chapter Four).
In the current climate of public-private partnerships, moreover, a cautious or
inquisitive attitude shown by a civil servant to a proposed interaction with a private
sector actor is often described as evidence of an ‘adversarial’ attitude towards the private
sector.48 This interpretation has exacerbated the frustration felt by experienced
international civil servants who have long dealt with the complexities of such
interactions and strived to ensure that they operate in the public interest. Some have
left the various UN agencies because they felt they could not maintain their integrity
in such a climate.49 They are gradually being replaced by civil servants who go along
with what is presented as a more ‘pragmatic’ approach. There is an urgent need to re-
value and strengthen caution and inquisitiveness as appropriate attitudes for civil servants
to adopt when interacting and negotiating with powerful commercial actors who are
operating in an increasingly competitive world.
A ‘win-win’ paradigm?
Another widespread perception is that entering into ‘partnerships’ with commercial
actors is a win-win situation for all concerned. Accepting this assumption at face value
carries large risks.
There are undoubtedly some interactions in which all parties have something to
gain and which are fully in the public interest (for example, in the development of
pharmaceuticals for neglected diseases, if these initiatives are well circumscribed with
appropriate safeguards for public interests). But an emphasis on ‘win-win’ tends to
lead to biased assessments. A more appropriate assessment needs to ask ‘who-wins-
what’ and ‘who-loses-what’. Gains or ‘wins’ for the commercial sector should not be
based on, or result in, losses from a public interest perspective.
Such losses, trade-offs and concessions can be far-reaching. Some broad and well-
established risks for society of the policy trend towards partnerships between the public
and private sectors include:
48 For example, Harvey E. Bale of The International Pharmaceutical Manufacturers’ Associations
(IFPMA) described the Guidelines as being “industry unfriendly.” According to him, they displayed a
negative bias against the private sector, which he saw as conflicting with WHO’s expressed interest in
partnerships. He criticized WHO’s approach to industry as overly defensive and suspicious and in
marked difference to the approach taken by other international organisations (WHO 2000d: 2).
49 For reasons why the former editor of WHO’s Essential Drug Monitor left, see for instance, Horton
2002a

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING 47
•commercial actors using the interaction to gain political and market intelligence
information in order to gain political influence and/or a competitive edge (over
companies that are not interesting enough to be ‘partners’ for UN agencies);
•business actors using the interaction to set the global public agenda;
•business actors using the interaction to ‘capture’ and/or sideline intergovernmental
public agencies;
•UN agencies developing an internal climate of censorship and self-censorship; and
•a weakening of efforts to hold transnational corporations publicly accountable
to society for their practices and actions (Utting 2000: 32, Richter 2003b).
For business partners, however, the balance between the potential risks and gains of an
interaction with a UN agency (or public interest group) looks very different. A few
years ago, a study on Global Public Private Partnerships for Health published in the
Bulletin of the World Health Organization concluded that:
“For the corporate sector, partnerships have (1) increased corporate influence in
global policy making and at the national level; (2) brought direct financial returns,
such as tax breaks and market penetration, as well as direct financial benefits through
brand and image promotion; (3) enhanced corporate authority and legitimacy
through association with UN and other bodies.”
As the authors pointed out, “the costs for the private sector seem to be relatively small
in relation to overall gains: a potential small loss of resources if programmes do not
work but huge benefits in public relations when they succeed” (both quotes, Buse and
Walt 2000b: 706).50
For the for-profit sector, in particular for those corporations who ‘partner’ with
UN agencies, the UN’s shift towards accepting the public-private partnership paradigm
has already paid off well. From a public interest perspective, however, many of the
gains for the corporate sector are losses. They are reflected in the weakening of the
ability of the UN agencies, their member states, and the world’s citizens to exercise
control over decision-making in the area of health policy-making, standard setting
and advocacy of public interests.51
50 There is the risk, however, of negative publicity if public attention is drawn to the potentially
problematic motives of the business party.
51 Many analyses of public-private partnerships focus on either the benefits or an evaluation of specific
public-private initiatives. Broader issues linked to the paradigm shift do not receive the attention they
deserve.

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING
48
Blurring of distinctions between societal actors
One of the most substantive losses resulting from the shift towards the partnership
paradigm is the loss of distinction between different actors in the international health
arena. UN agencies, governments, transnational corporations, their business
associations, and public interest NGOs are all indiscriminately called ‘partner’.
The realisation that these actors have different, possibly conflicting, mandates, goals
and roles has, as a result, also been lost.52 One recent analysis of the partnership trend
as part of a more general shift within international relations pointed to another political
consequence:
“It is problematic to use the term ‘partnership’ to characterize the relationship
between state and non-state actors, because what the term suggests is an … equal
status for the actors involved. This relativizes both, the special political status of
governmental institutions under international law and their (democratic) legitimacy.
The use of terms like ‘partnerships’ is … not just a matter of stylistics, it has eminently
political significance. It implicitly downgrades the role of governments and
intergovernmental organisations and upgrades the (political) status of private actors,
in particular of the transnational corporations involved in these cooperation models.”
(Martens 2003: 26)53
Checks and balances
Assessment of the evolution and current state of WHO’s public interest safeguards
suggests that the stumbling blocks towards putting more comprehensive safeguards in
place and linking them firmly to an underlying ethics and conflict of interest framework
are as much political as they are caused by the complexities of the issue.
The rise of the partnership paradigm has meant that measures to deal effectively
with conflicts of interest are regarded not as safeguards but as obstacles. The underlying
assumptions of the partnership paradigm and its accompanying terminology have
blurred the roles of different actors within institutional and international policy arenas.
Conflict of interest theory may help to overcome some of these stumbling blocks
and ensure a more coherent, ethics-based policy to guide WHO’s public-private
interactions in the field of health.
52 This would suggest that problems today go beyond what might be called ‘institutional capture’.
53 For another interesting exploration, see also “Partnership: What’s in a name?, in Zammit 2003: 51–
54.

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING 49
There is now a fair amount of knowledge and thinking about conflicts of interest
generated by interactions between economic and other societal actors in many fields.
Relevant knowledge and thinking can be found in the literature on conflicts of interest
in public service, medical research and science and in treatises on how to ensure
democratic decision-making in a globalising world. This would need to be
complemented, however, by a thorough analysis of the experiences of WHO staff who
have been involved in cooperative relationships with private sector actors and those
who have managed to fend off industry pressure on WHO to enter into relationships
that the staff regard as conflicting with WHO’s mandate or core functions or as posing
a risk to WHO’s reputation as the UN agency striving for Health for All.
Since 1998, one problem in learning from this experience has been that the focus
of attention has often been narrowed down to the tobacco industry. Several WHO
officials, including Dr. Brundtland, have made a stark distinction between tobacco
manufacturers, which they describe as ruthless marketers of a killer product, and other
industries, which are portrayed as producers of health-related products and thus as
potential sponsors or project and dialogue ‘partners’ (or ‘stakeholders’) with whom
interactions should be encouraged.
Lessons which can and should have been drawn from experience with the
pharmaceutical, infant food, junk food and alcohol industries over the past two
decades54 are all too often dismissed as stemming from an outdated ‘adversarial’
framework (confounding ‘arms length’ with ‘inimical’ approaches). Or they are
described as an obstacle to more ‘constructive’ and ‘innovative’ ways of engaging with
commercial actors.
For example, food industries and organisations founded by or close to the food
industry were ‘stakeholders’ in discussions on WHO’s Global Strategy on Diet, Physical
Activity and Health. Concerns that such industry involvement in the policy-making
process might dilute the strategy, particularly plans to recommend regulating the
marketing of junk foods and soft drink high in sugar content to children, were not
taken seriously enough. WHO’s project manager stated repeatedly that “food is not
tobacco”. She argued that tobacco kills half its users, while “this is not the case with
food” given that “we all need to eat and wish to enjoy the food we consume” (Waxman
2003). WHO tried to win member states, public interest and professional organisations
over to a policy of positive engagement. The result is a Global Strategy on Diet with
54 For example, Chetley 1990; Kanji et al. 1992; Gellman 2000a; Gellman 2000b; Velásquez 2004;
Richter 2001; Cabasse 2004; Rundall 2000; Babor, Griffith et al. 1996; Hirschhorn 2002; Boseley
2003a; Boseley 2003b; Alden et al. 2004; Down to Earth 2004; Commercial Alert 2004.

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING
50
many positive elements but also with many shortcomings, the seriousness of which
can be assessed fully only once the Strategy starts to be implemented.
In considering how to reclaim a clearer baseline of values by which to assess
interactions with the private sector, it must be emphasized that developing an
appropriate strategy to safeguard public interests needs above all an understanding
that conflict of interest policies evolved as an important (but not the only) part of
intricate systems of checks and balances in democracies, medicine and the sciences.
Their development and implementation should not be seen as troublesome task, but
rather as a key prerequisite to a well-functioning public institution.
Some parts of such systems can be formalised, others not. At issue is the need to
recover, maintain and strengthen institutional and societal environments that encourage
internal and external checks and balances to ensure that close proximity to money and
power does not lead to harmful consequences for public interests, that it does not
corrupt.
Facilitating the input of public interest NGOs
When Dr. Brundtland presented WHO’s existing or envisaged measures to manage
public-private interactions and conflicts of interest to the Executive Board in January
2002, she seemed to take the question of balances of power and external checks into
consideration. The measures she outlined explicitly referred to WHO’s newly founded
Civil Society Initiative (CSI) and its task of facilitating “the input of nongovernmental
organizations views pertaining to public-private interactions” (WHO 2001: 3) (see
also Box 1, p. 16).
To what degree was there a high-level commitment to facilitate independent critical
input into debates on public-private interactions (other than the debate on the
Framework Convention on Tobacco Control)? The CSI had the potential to do so,
but its work in practice has increased the risks of industry gaining yet more opportunities
for influence in the international health arena and of weakening the input of those
civic actors that have historically acted as corporate watchdog groups.
The Civil Society Initiative
Dr. Brundtland launched the Civil Society Initiative at the World Health Assembly in
2001 as part of her overall ‘outreach’ effort. The stated purpose of the Initiative was to
collect and analyse material and to consult with a broad range of actors within and
outside of WHO to identify and develop propositions for more effective and useful
interactions and relationships between civil society and WHO. When this work started,

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING 51
civil society was defined as including social movements, voluntary associations, NGOs,
grassroots organisations and other non-state, not-for-profit actors (in WHO/CSI 2002: 2).
The Civil Society Initiative did initially seem to work towards its stated purpose.
Its 2002 Review Report, which summarised the findings of a consultation process,
mentioned that WHO had benefited from civil society organisations’ (CSOs) watchdog
function in protecting public health and from their ability to raise “sensitive issues
that WHO, as an intergovernmental organization, may not be in position to address
for political reasons.” It also mentioned that greater involvement of civil society
organisations might help democratise international relations and increase transparency
and public accountability in international policy development (WHO/CSI 2002: 13).
Its report highlighted a number of key concerns raised by civil society organisations
during the consultations, in particular:
1. The lack of distinction in WHO’s 1987 NGO relations policy between public
interest NGOs (PINGOs) and business interest NGOs (BINGOs); and
2. The insufficiency of WHO’s safeguards on conflicts of interest (WHO/CSI
2002: 14).
It stated that civil society voices were urging that “business-linked organizations be
classified as the private (for profit sector) and not fall within the NGO/CSO
classification” and that WHO “build on WHO’s Guidelines for interactions with
commercial enterprises and supplement them with additional measures” in order to
appropriately deal with conflicts of interest (WHO/CSI 2002: 9; 14).
Why then did the Civil Society Initiative not take these comments into account
when updating the 1987 Principles Governing Relations between the World Health
Organization and Nongovernmental Organizations (WHO 1987)?
New WHO policy for official relations with NGOs
The draft of a new Policy for Relations between the World Health Organization and
Nongovernmental Organizations (henceforth WHO’s NGO relations policy) was posted
on WHO’s website in November 2002 and described as the outcome of a desk review
and consultation process (WHO 2002). During a WHO briefing session for NGOs
one month later, some initial questions about the revised policy were raised.
Why, for instance, did the policy not distinguish more clearly between business
interest and public interest actors? If the policy was to include business actors within
its scope, why did it not make a clear reference to the WHO Guidelines for Interaction
with Commercial Enterprises to Achieve Health Outcomes?
When the Civil Society Initiative introduced the draft WHO-NGO relations policy
at the Executive Board in January 2003, several Executive Board members voiced

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52
similar criticisms to those raised by NGOs. They welcomed the idea of subdividing
the policy into an ‘Accreditation Policy’ and a ‘Collaboration Policy,’ but were concerned
that, on the whole, the policy was formulated in a way that might increase the influence
of the commercial sector over public policy-making and multiply conflicts of interest.
Ghana, Brazil and Colombia demanded that the policy make a clearer distinction
between organisations that served the public interest and those that represented or
were closely linked to business interests. Some member states highlighted the need for
WHO’s mechanisms to safeguard its independence, objectivity and reputation to be
improved and strengthened further.
The United States agreed that clearer legal and ethical principles should be established
to deal with conflicts of interests, but opposed ‘singling out’ for-profit organisations.
In the opinion of the US delegate, there were many non-profit organizations, including
governments that did not always have the best interests of the public at heart.
The US delegate specifically requested that a paragraph in the draft policy stipulating
that “collaboration with nongovernmental organizations representing commercial
interests shall also follow WHO mechanisms and practices for interacting with
commercial enterprises” be deleted because he saw the language as too narrow. He
argued, furthermore, that WHO’s Executive Board had never officially approved the
mechanisms and practices for interacting with commercial enterprises.
Ghana’s representative stressed, however, that the criticised paragraph should not
only remain but be further strengthened by making explicit reference to the Guidelines
on Interaction with Commercial Enterprises to Achieve Health Outcomes (WHO 2003b:
170–178).
Controversial debates continued at the 2003 World Health Assembly. Questions
were raised as to the appropriateness of changes that had been introduced in the draft
policy after the Executive Board meeting in January 2003. Why, for example, had
WHO expanded the proposed new definition of nongovernmental organisations to
explicitly include “non-for-profit organizations that represent or a closely linked with
commercial interests” (WHO 2003c, para 3)?
Debate was curtailed by China’s last minute tabling of extensive changes aimed at
gaining more government control over NGOs rather than facilitating their interactions
with WHO.
Reaching agreement on both China’s proposal and diverging views on the
accreditation of and collaboration with not-for-profit business interest actors was clearly
going to take some time. Thus the World Health Assembly deferred further debate on
the draft policy to the 2004 Executive Board meeting.
The draft was tabled, unchanged, at this Executive Board meeting. But discussion
was limited because the WHO Secretariat, in consultation with Executive Board
members, had already decided to refer the matter to a working group of member states

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING 53
to discuss the policy and the accompanying resolution and to present proposals to
resolve the contested issues at the 2004 World Health Assembly.55
Public interest NGOs pointed out in their statements to the Executive Board that
the new expanded NGO definition constituted a fundamental shift from WHO’s
1987 Principles Governing Relations between the World Health Organization and
Nongovernmental Organization. They reiterated their suggestion that WHO should
establish a private sector category that was distinct and separate from civil society,
including NGOs. They called for an independent external review of all the mechanisms
to safeguard WHO’s integrity and independence.56
A representative of the International Special Dietary Food Industries (ISDI),
meanwhile, spoke out at the January 2004 Executive Board meeting in favour of
adopting the draft policy as tabled because:
“The United Nations community recognizes the industry as an important stakeholder
and partner. UN organizations have long recognized that NGOs representing
consumers, business and industry are important sources of knowledge, technology
and resources.” (ISDI 2004a, emphasis added)
The representative rejected any measure aimed at distinguishing between not-for profit
entities representing commercial interests and other not-for profit actors on the grounds
that this would constitute unjust discrimination. The ISDI was categorical that “all
NGOs should be afforded the same rights to participate and collaborate in WHO
processes, including access to the WHA and Executive Boards sessions” (ISDI 2004a).
55 An item on the Executive Board meeting’s January 2004 agenda before the draft NGO policy
highlighted the issue of accrediting business interest organisations as NGOs in official relations with
WHO. The Executive Board’s Standing Committee on Nongovernmental Organizations had
recommended that two industry groups be admitted into official relations with WHO: the International
Council of Grocery Manufacturers Associations (ICGMA) and the Confederation of the Food and
Drink Industries of the EU (CIAA) (WHO 2004a). Its recommendation document was issued on the
morning of 23 January, the very day on which member states were to consider approval of the
recommendation.
Thirteen member states spoke on the issue. Some pointed to the discrepancy between the Standing
Committee’s recommendation and WHO’s existing (and still valid) 1987 NGO policy. The questions
and objections from the floor resulted in the Board postponing a decision on the two applications until
further information had been obtained on both industry groupings and their links with the tobacco
industry.
56 CI et al. 2004, Infact 2004. See also Summary of Key Concerns Regarding the Proposed WHO Policy for
Relations with Nongovernmental Organizations, IBFAN et al. 2003.

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The International Pharmaceutical Manufacturers Association (IFPMA) also
expressed its opposition to any attempt to identify business interest actors more clearly.
Both industry groupings stressed their long-time ‘partnerships’ with WHO and their
multi-sector cooperation.
Following the 2004 Executive Board meeting, three closed meetings of the member
states’ working group took place. Their suggested changes to the draft policy, however,
did not include a clearer distinction between business and other societal actors. The
NGO definition remained unchanged and continued to identify business interest actors
as nongovernmental organisations:
“An organisation that is not established by a governmental entity of intergovernmental
agreement shall be considered a nongovernmental organisation … For the purpose
of this policy, nongovernmental organisations include a wide range of organisations,
such as groups that represent consumers and patients, associations with
humanitarian, developmental, scientific and/or professional goals and not-for-profit
organisations that represent or are closely linked with commercial interests.” (WHO
2004b: 3, para 4)
This definition, if accepted, could well result in increased avenues for industry influence
in the international health arena.
But the member states’ working group did put two paragraphs into the draft
resolution requesting:
“the Director-General to establish suitable measures to implement the policy,
including… clear and specific guidelines on avoiding conflict of interest” (WHO
2004b: 2, para 3); and that
[the Director-General to institute, [an external, independent review of ] mechanisms
to safeguard WHO’s integrity and independence, including the WHO’s Guidelines
for Interactions with Commercial Enterprises]. (WHO 2004b: 2, para 5)
The brackets around, and in, the second paragraph indicate that the second request
was highly contested within the meetings of the member states’ working group. Whether
both paragraphs would be retained and the policy adopted at the May 2004 World
Health Assembly would depend on political will, power balance and negotiation skills.

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING 55
Towards a review of WHO’s safeguards?
Before the May 2004 World Health Assembly, any prediction as to the outcome of the
debates on the Policy for Relations between the World Health Organization and
Nongovernmental Organizations was difficult to make. Clearly, retaining the second
paragraph in its entirety could be a promising step towards more clarity in WHO’s
public interest safeguards. Any hopes of this, however, were short-lived.
The debate among the WHO member states on the resolution and policy was
brief. It focused on China’s wish for more control over NGOs, with three countries
(China, Pakistan and Cuba) arguing in favour of more government control. Sweden
spoke against such a move, stressing its support for democratic traditions. Canada,
USA, The Netherlands and the UK said that they too could not support this section
of the draft policy. Canada thus suggested postponing any decision on the NGO
policy until the final report of the UN Secretary-General’s Panel of Eminent Persons on
United Nations-Civil Society Relations was published. The various positions of the
member states were too far apart for any consensus to be reached. The 2004 World
Health Assembly thus decided “to provide the Director-General with time to consult
all interested parties with a view to reaching consensus on the terms of the relevant
resolution to be submitted to a subsequent Health Assembly through the Executive
Board.” Following this decision, public interests and other NGOs were given the floor.
The food and pharmaceutical industries repeated the positions they had presented
at the January 2004 Executive Board meeting. The ISDI suggested that “non-
discrimination” should become one of the two core principles on which any WHO-
NGO relations policy should be built (ISDI 2004b).57 58
Several public interest advocacy networks responded that the industry groupings’
concern about negative discrimination was unwarranted. Collaboration with business
57 On the ISDI website is a statement from the organisation for the WHA 2003 (which to my knowledge
was not delivered). This states that efforts to reform accreditation and collaboration requirements for
NGOs “must retain the principle of non-discrimination instituted in the current WHO policy and
guidelines” (ISDI 2003). In other words, “All NGOs should be afforded the same rights to participate
and collaborate in WHO processes, including access to the WHA [World Health Assembly] and Executive
Board sessions” (ISDI 2004a). It seems that the industry even rejected as discriminatory a plan to
distribute different coloured badges for business interest organisations and other NGOs (a measure that
had been envisaged to allow member state delegates discern to whom they were talking when being
approached by NGO representatives).
58 The other was ‘transparency.’ According to this industry association: “all NGOs should be subject to
the same high levels of scrutiny, and accountability and should be required to disclose affiliations and
funding sources, and demonstrate that they do, in fact, represent the constituency they claim to represent”
(ISDI 2004a).

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING
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associations clearly came within the scope of the WHO’s Guidelines on Interaction with
Commercial Enterprises. These Guidelines defined commercial enterprises as “businesses
that are intended to make profit for their owners”, but encompassed a variety of other
institutions as well, “including … associations representing commercial enterprises,
[and] foundations not at arms length from their sponsors” (WHO 2000b, para 2 &
3). The NGOs suggested that WHO refine this definition further and think afresh on
policies for accreditation (CI et al. 2004).
The future of the draft WHO-NGO relations policy is uncertain. Will it be resolved
so as to genuinely facilitate civil society actors’ contribution to the work of WHO and
its member states for Health for All? Does its postponement at the 2004 World Health
Assembly to an unspecified ‘subsequent’ Executive Board meeting and World Health
Assembly augur its death-knell? Or will associations of transnational corporations
actively lobby for the adoption of a version that further facilitates their acceptance as
NGOs in official relations with WHO?
Canada hoped that the UN Secretary-General’s Panel of Eminent Persons on United
Nations-Civil Society Relations might clarify some of the issues.59 But given the Panel’s
terms of reference and the trajectory of its work, it is doubtful that its report will help
to resolve issues as to whether industry associations should be specifically included
within UN NGO definitions or will raise questions about the potential for this NGO
status to enable the associations to gain undue industry influence in public affairs.60
59 Thanks to Lida Lhotska, IBFAN-GIFA, for sharing her notes of the May 2004 Executive Board
meeting.
60 The High-Level Panel’s terms of reference are themselves confusing. Their task is to advise the UN
Secretary-General on priorities for “enhancing interaction between the Organization and civil society,
including parliamentarians and the private sector” (emphasis added).
In a working paper, the Panel tried to make a better distinction between different actors but stressed that
its results were not an official UN classification. It defined ‘civil society’ as “the associational activity of
citizens (outside their families, friends and workplaces) that is entered into voluntarily to advance their
interests, ideas, ideals and ideologies. It doesn’t include associational activity of people for profit-making
purposes (the private sector) or for governing (the state or public sector).” The Panel defined ‘private
business sector’ as including “for-profit firms, their federations and philanthropic initiatives emanating
from firms” (UN 2003a).
This distinction was lost, however, in the summary of a Multi-stakeholder Workshop on Partnership
and UN-Civil Society Relationships held by the High-Level Panel. Under the heading ‘Civil society’
and ‘other actors’, it states that “It is important to be inclusive in our conception of civil society, to look
beyond the ‘usual suspects’ and seek out the potential contributions and roles of diverse actors including
not only NGOs but also professional associations, local authorities, organized labor, private sector, faith-
based and community-based groups and ‘unorganized’ social movements. Although groups such as
parliamentarians, local government and private sector are not traditionally seen as belonging to ‘civil society’,
the UN has a practical need to engage with all these diverse actors to achieve global goals” (UN 2004).

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING 57
Ever since the UN first created the category of nongovernmental organization in
1946 for not-for profit, non-state actors, industry associations have been able to apply
for, and usually obtain, NGO status on the basis that they, too, are not-for-profit. Their
admission as NGOs in consultative status has depended on two long-standing practices:
1. conflating ‘not-profit making’ and ‘not working in the interest of profit’ (an
organization might well itself make no profits, but its aims and objectives are to
work in the interest of others’ making profits); and
2. disregarding another requirement for UN NGO status, namely that the
organisation should share the UN’s values.
For example the 1996 UN’s Economic and Social Council’s Resolution on Consultative
Relationships between the United Nations and Non-governmental Organizations, which
currently governs decisions as to which NGOs gain consultative relationship status
with the United Nations, specifies that “the aims and purposes of the organization
shall be in conformity with the spirit, purposes and principles of the Charter of the
United Nations” (ECOSOC Resolution 1996/31, para 2).
Similarly, WHO’s 1987 Principles Governing Relations between the World Health
Organization and Nongovernmental Organizations require that the NGO’s “aims and
activities shall be in conformity with the spirit, purposes and principles of the Constitution
of WHO” (WHO 1987, para 3.1, emphasis added).
There are exceptions, however, to the routine admission of non-profit making
business associations as UN NGOs. In the early 1980s, for example, WHO’s Executive
Board deferred the application of the International Council of Infant Food Industries
(ICIFI) three times because of evidence that the industry association members had
been undermining WHO members states’ implementation of the International Code
of Marketing of Breast-milk Substitutes and had continued pursuing harmful marketing
practices. The infant food manufacturers thus changed their strategy. They dissolved
ICIFI and formed another business association, the International Association of Infant
Food Manufacturers (IFM). This association asked WHO’s Secretariat what its chances
were of being accepted as an NGO in official relations with WHO. When it learnt
that its chances were not good, it joined an existing industry body, the International
Society of Dietary Food Industries (ISDI). This industry umbrella association then
applied for the status of an NGO in official relations with WHO, which it gained in
1987.61
61 The infant food industry shared its experience with other TNCs in a newsletter on ‘How companies
can gain from NGO status’. For more details, see Allain 1991: 26–7, 36; Chetley 1986: 28, 81, 148–9;
Sethi 1994: 23.

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING
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Interestingly, in 2004, WHO member states once again adopted a more critical
attitude towards business associations, probably because of their heightened awareness
of successful industry resistance to the adoption of a strong Global Strategy on Diet,
Physical Activity and Health.62
Such awareness had led the January 2004 and May 2004 Executive Board meetings
to defer the admission of two other food industry groupings – the International Council
of Grocery Manufacturers Associations (ICGMA) and the Confederation of the Food
and Drink Industries of the EU (CIAA) – as NGOs with official relations status with
WHO.
A few member states, in particular the United States, regarded this deferral as
inconsistent with the anticipated ‘multi-stakeholder’ implementation of the Global
Strategy on Diet. The US delegate seemed to interpret multi-stakeholder initiatives as
unconditional blanket admissions of industry to all discussions. Other member states
pointed out that, in fact, WHO consultations with these associations did not depend
on their having the status of NGO with official relations. WHO and its member
states can consult with industry and their associations if they see this as being in the
public interest.
Several countries expressed their discomfort that the role of TNCs in implementing
the Global Strategy on Diet is poorly defined and that some of the member companies
of the Grocery Manufacturers Association had ties with tobacco companies. During
the May 2004 World Health Assembly debate on the Global Strategy on Diet, the
European Union representative had suggested that the role of TNCs should be reviewed
in the near future and pointed to the Framework of Convention on Tobacco Control
as a document that more clearly defined appropriate industry roles (EU 2004).63 64
As of June 2004, it is uncertain whether the WHO Secretariat and member states
will find new vigour and political will to work on two different sets of accreditation
and collaboration policies for NGOs, one for civil society non-state actors and another
one for those who work in the business interest. This might not be an easy task because
the boundaries between the two are not necessarily clear-cut. While industry associations
and industry-founded research organisations can be categorised easily, industry
sponsorship of patient groups, health professional associations, and public interest
advocacy organisations constitutes more of a challenge.
62 For more information, see, for instance, Alden et al. 2004; Down to Earth 2004; Commercial Alert
2004.
63 Other countries aligned with the statement were Bulgaria, Romania, Turkey, Albania, Bosnia-
Herzegovina, Croatia, and the Former Yugoslav Republic of Macedonia, Serbia and Montenegro.
64 It may also be useful to compare the Global Strategy on Diet with WHO-UNICEF Global Strategy on
Young Child and Infant Feeding (2003) (see, in particular, paras 35 and 44).

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING 59
Whatever the outcome of the ongoing debate about WHO’s official relationships
with NGOs, a better delineation between business interest and other non-state actors
is indispensable to developing better safeguards in the global health arena. Such a
distinction does not in any way constitute a discrimination of industry associations.
The industry stand is inconsistent. Industry associations and major transnational
corporations do not usually oppose being singled out as privileged ‘private sector’
participants in public matters and public-private partnerships. Yet, at the same time,
they want to be classified as ‘NGOs’, ‘stakeholders’, ‘partners’ or ‘constituency’ when
this serves their interests.
A long-standing mandate
The fact that the 2004 World Health Assembly did not adopt the new NGO policy
and the accompanying resolution should not be interpreted as a signal for WHO to
take no action. If it had been adopted, the resolution would have requested WHO’s
Director-General “to establish ... clear and specific guidelines on avoiding conflict of
interest …[and to] to institute, an external, independent review of mechanisms to
safeguard WHO’s integrity and independence, including the WHO’s Guidelines for
Interactions with Commercial Enterprises.”
This would not, in fact, have given the Director-General a new mandate. It would
only have reinforced an existing one to review WHO’s safeguards, a mandate nearly as
old as WHO’s move towards partnership interactions with the commercial sector. The
fulfilment of this mandate is long overdue. At the Executive Board session in January
2000, Board Members stressed the need for transparency and avoidance of conflict of
interests in public-private relationships. Two years later at the Executive Board meeting
in January 2002, Dr. Brundtland clarified that the Guidelines for Interactions with the
Commercial Sector to Achieve Health Outcomes “will be updated regularly to reflect
experience and will include text on recognizing and avoiding conflict of interest” and
that “staff training modules on issues relating to private-sector interaction and conflict
of interest are being developed” (see WHO 2000c; and WHO 2001).
The ‘Implementation Review’ section of these Guidelines states that “The application
and impact of these guidelines shall be periodically reviewed.” The ‘Procedures for
Implementation’ section announces that “If appropriate, the present guidelines will be
updated (for example, in the event of a change in policy or an unprecedented case).”
In the course of my interviews, concerns were expressed that, in the light of the
current power constellations within the international arena, any review of the Guidelines
on Interaction with Commercial Enterprises could lead to WHO’s safeguards being
weakened rather than strengthened.

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING
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Indeed, if the option favoured by the US and some key industries was adopted, a
review process would probably lead to guidelines and policies that blurred still further
the distinctions between the different roles, obligations and rights of business interests
and other societal actors in public health matters.
If, however, the review pursued the demands expressed by other member states and
public interest NGOs, the review process might well lead to a framework allowing for
better guidance and management of the various types of interactions between WHO
and business interest actors. The direction and outcome of such a review of public
interest safeguards would depend primarily on the analytical clarity and political will
of WHO’s member states and its new Secretariat under Dr. Jong-wook Lee.
Any review of WHO public interest safeguards governing public-private interactions
needs to yield clear guidance for WHO staff and member states on how best to assess
and classify public-private interactions (including ‘multi-stakeholder dialogues’) and
to avoid and/or manage conflicts of interest in these interactions appropriately. The
review process could itself open up public debate about the value of – and potential
alternatives to – the partnership model for public sector interactions with industry.
The key question is how to bring about such a review.

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING 61
3. Safeguard issues in the global arena
Legally independent global health alliances
A review of WHO’s guidelines and policies and an opening up of the public debate are
critical steps – but they would not by themselves safeguard public interests in the
international health policy arena. This is partly because several policy and partnership
initiatives that are beyond WHO’s immediate control are having an immense impact
on public health policy making and institutional structures.
These include ‘global health alliances’ (also known as global public-private
partnerships for health or global funds) and the guidelines for interactions with the
private sector issued by UNICEF and the United Nations itself.
The three most well know global health alliances today are the Global Alliance for
Vaccines and Immunization (GAVI), the Global Alliance for Improved Nutrition
(GAIN), and the Global Fund to Fight Aids, TB and Malaria (GFATM).
GAVI and GAIN owe their existence to multi-million dollar donations from the
Bill and Melinda Gates Foundation. Microsoft founder Bill Gates and other Seattle
and Silicon Valley hi-tech millionaires and billionaires adhere to the Californian venture
philanthropy model. This model is characterised by active involvement of the ‘charity
entrepreneurs’ and their foundation’s staff in the activities and running of the recipient
organisations or alliances. Most Californian-style venture philanthropists “demand
seats on the boards, set performance goals and plan an exit strategy in case expectations
are not met” (Piore 2002).65
These two large health alliances initiated by the Gates Foundation seem to have
come with several conditionalities attached. Recipients have to agree to the private
sector having decision-making power on the governing bodies of the initiative at
international and national level; the money being catalyst funding for a limited period
of time only; and to funds from donor and recipient countries complementing and
65 The key notion behind this model – that private charity should replace government spending on
public services and welfare – was introduced in the 1980s by US President Ronald Reagan. Twenty
years later in the UK, with the advent of “the Blairite vision … not to redistribute wealth through
taxation, but to encourage business to make a profit while ‘enabling’ the poor to dig themselves out of
the ditch,” this notion is also firmly entrenched in Britain (Coote 2002). The generosity of venture
philanthropists has been substantially aided and abetted by a massive restructuring of public taxation
systems in recent years. To what extent can these supposedly new and untapped resources be considered
as diverted tax income – money that is missing from public resources for welfare and development
programmes and services?

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING
62
later replacing the Gates Foundation money. Both health alliances focus on technology-
driven health interventions: GAVI on vaccines, and GAIN on micronutrient provision.
The third major global health alliance, the Global Fund to Fight AIDS, TB and
Malaria (also known simply as the Global Fund) was set up by the UN Secretary-
General in 2001. The great majority of its funding comes from public sources. Yet the
Global Fund was structured as a public-private partnership in which an industry
representative has voting rights on the board, but WHO has none.
These three high-level global health initiatives are legally independent bodies whose
lines of accountability are exceedingly complex.66 WHO’s member states have been
side-players in their establishment and operations. A proliferation of such global health
partnerships may fragment international health policy-making and programmes, and
undermine WHO and national decision-making capacities. They may also divert funds
away from WHO and from more holistic, less technology-centred, sector-wide
approaches to health care (see, for example, Ollila 2003b; Zammit 2003).
Civil servants need to put in substantial time to these global health alliances in the
form of technical support and advice. No estimate of what supporting these alliances
actually costs WHO and its member states in terms of diverted funding and staff time
has been calculated and publicised.67 One WHO official raised concerns during our
interview about the time that the current WHO Director-General had to spend on
attending GAVI board meetings.
Another important type of global health ‘partnership’ is that between WHO and
the pharmaceutical industry. Many of them, in particular some of the big drug donations
programmes and access to drugs initiatives, may reflect the industry’s desire to influence
policy debates, particularly those on the World Trade Organisation’s intellectual property
agreement, TRIPS, and on drug pricing and access to drugs. One UNICEF official
wondered during the course of our interview whether high-profile partnerships with
pharmaceutical companies had delayed rather than improved poorer people’s access to
anti-retroviral drugs and other essential medicines.68
Three UN leaders – WHO’s former Director-General, Gro Harlem Brundtland;
UNICEF’s Executive Director Carol Bellamy; and the UN Secretary-General Kofi
Annan – have all been instrumental in launching these public-private initiatives in the
66 See, for example, Starling, Brugha et al. 2002:5–8; Heimans 2002: 16; Ollila 2003b: 48–54. For the
most recent updates, see the websites of the respective global health alliances.
67 This contrasts with the value placed on industry input. A study by the Initiative on Public-Private
Partnerships for Health values the input of industry experts on the boards of product development
alliances at US$11,000 per day in terms of ‘forgone compensation’ (Kettler, White et al. 2003: 14).
68 Some interesting information in this respect can be found, for instance in Gellman 2002a; Zammit
2003: 247; Beigbeder 2004.

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING 63
international health arena. Today’s UN leaders could use their office to support calls
for a thorough, independent and public re-evaluation of these types of arrangement so
that institutions have better guidance on their impact and risks and can obtain a sounder
basis for decision-making before any more high-level global health alliances are initiated.
WHO’s publicly available Guidelines for Interaction with Commercial Enterprises to
Achieve Health Outcomes do not offer much guidance as to how the Organization
should deal with such large social experiment initiatives, even though GAVI was
launched more than four years ago in January 2000 at the World Economic Forum
(WEF). They make a cursory reference to the “establishment of multiple-party alliances”
by requesting that they “should be referred to the Director-General, after due
consideration by the Executive Director or Regional Director concerned and the Office
of the Legal Counsel” (WHO 2000b, para 47). They do not suggest that WHO should
engage in a broader consultation, for example, with its member states and relevant
public interest NGOs. UNICEF’s guidelines, Building Alliances for Children: UNICEF
Guidelines and Manual for Working with the Business Community – Identifying the Best
Allies, Developing the Best Alliances, do not cover global health alliances at all.
UNICEF
This publication has outlined the development public interest safeguards within WHO.
Other UN agencies have also made attempts to institute public interest safeguards.
The experience of UNICEF and the United Nations itself may provide further insights
for those concerned about safeguarding public health.
UNICEF Executive Director Carol Bellamy cautioned in 1999:
“It is dangerous to assume that the goals of the private sector are somehow
synonymous with those of the United Nations, because most emphatically they are
not. Business and industry are driven by the profit motive – as they should be and
must be, both for their shareholders and their employees. The work of the United
Nations, on the other hand, is driven by a set of ethical principles that sustain its
mission - principles of the Charter of the United Nations, in the Universal
Declaration of Human Rights, in the Convention on the Rights of the Child, and
elsewhere in the galaxy of international instruments and treaties that have been
promulgated since the UN’s founding in 1945 [...]. In coming together with the
private sector, the UN must carefully, and constantly, appraise the relationship.”
(Bellamy 1999)

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Despite these words of caution, UNICEF’s safeguards have been developed in an even
less public process than that within WHO. Three years after they were issued, the
agency’s detailed Guidelines and Manual for Working with the Business Community are
still not available either to the public or to collaborating public interest NGOs. A two-
page executive summary is all that can be obtained upon request (UNICEF 2001b).
UNICEF executives initially explained that the full text of the Guidelines was being
kept strictly internal because making them publicly available might deter commercial
partners from entering into alliances with the agency. UNICEF also considered the
document to be a ‘business secret’ (Ollila 2003c: 65; Richter 2003a).
Part of the secrecy might be because many UNICEF alliances focus on fundraising.
Disclosure of UNICEF’s detailed guidance on how the agency interacts with its
corporate sponsors might be perceived as disclosure of a coveted fundraising tool,
given the competition with other UN agencies for limited corporate funds.69
A more recent explanation given for UNICEF’s reluctance to release its detailed
Guidelines is that they are internal operational guidelines that were not drawn up with
the public in mind. According to UNICEF’s Director of Private Sector Division, the
Guidelines are currently being revised and should be publicly available at the end of
2004.
Some UNICEF field staff, however, have felt that the secrecy surrounding the
Guidelines runs counter to the democratic principle of the public’s right to know.
They felt that it conflicted with the general principle of transparency enshrined in the
UN’s Guidelines on Cooperation between the United Nations and the Business Community
(UN 2000: paras 14, 19b). This is the route by which, eventually, a copy of the
UNICEF’s detailed Guidelines was made available for this research. (UNICEF 2001a)
A review of these detailed Guidelines and Manual for Working with the Business
Community raises questions as to whether the secrecy surrounding them moreover
stems from the fact that they contradict to a certain extent the Summary that had
been publicly released.
The Executive Summary, for instance, strictly prohibits UNICEF from endorsing
companies or products. Under the heading No endorsement, it categorically states that
“UNICEF does not endorse any products, goods or services. At no time may any
UNICEF office, staff member of UNICEF National Committee endorse or appear to
endorse a company, group of companies, industry sector or third party, its products or
services” (UNICEF 2001b).
69 Thanks to Eeva Ollila, National Research and Development Centre for Welfare and Health (STAKES),
for this observation.

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING 65
Yet the detailed Guidelines provide meticulous explanations on how best to place
UNICEF’s label on corporate products – a practice called ‘co-branding’ in trainings of
the National Committees for UNICEF. The detailed Guidelines specify substantial
financial thresholds that corporations wishing to become corporate sponsors or to
engage in national, regional, and international joint fundraising alliances must reach
(UNICEF, 2001a: 41–2; 26).70
Like WHO, UNICEF does not have an institutional definition of conflict of interest.
A debate on how to bring the issue into its safeguards and policies on alliances with
the business community has yet to take place. The UNICEF Executive Board seems
less open to public and controversial debate than WHO’s governing bodies. Yet since
the Guidelines are being revised, this would be an opportune moment for UNICEF
to work at seeking public comment. A more public process could help to prevent
UNICEF’s revised Guidelines – and the agency’s future practice – from being in conflict
with international policy making in the area of health and other fundamental human
rights.
UNICEF has engaged in several dubious business interactions, for instance,
sponsorship alliances with McDonalds and Coca Cola. These enhanced the reputation
of the food industries at a time when WHO and its member states were pointing out
the harmful effects of junk food and sugary drinks on children’s health. These alliances
also prompted questions about whether UNICEF had violated its mandate to protect,
promote and fulfil children’s rights.71 Questions were raised most recently when Abbott
Ross, a known violator of the International Code of Marketing of Breast-Milk
Substitutes, distributed UNICEF’s 2004 diary, co-branded with its company logo, to
physicians in the Middle East.
United Nations Guidelines and the Global Compact
The United Nations itself issued Guidelines on Cooperation between the United Nations
and the Business Community in July 2000. A primary aim of these Guidelines was to
foster policy coherence within the UN. Like the WHO Guidelines, these UN
Guidelines are available on the UN website.72
70 Questions have been raised about the degree to which UNICEF’s liberal exchange of its logo for
corporate funds, particularly its minimum recommended financial thresholds of US$100,000 for National
Alliances, US$250,000 for Cross-Border Alliances, and US$500,000 for International Alliances, “stretch
the limits of jurisprudence”. For more details, see Tesner with Kell 2000: 79–81.
71 See, for instance, Zammit 2004: 61; Richter 2003a: 9.
72 www.un.org/partners/business/otherpages/guide

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING
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The UN Guidelines stress that the Secretary-General’s Global Compact (a high-
level policy partnership between business community, the UN and other ‘stakeholders’)
provides the overall framework for co-operation with the business community. They
advise UN organisations to use the Global Compact’s nine universally-accepted
principles from the fields of human rights, labour and environment as reference points
in their co-operation with the business community and they encourage them to add
additional criteria specific to their mission or mandate (UN 2000, para 12).73
Consequently, these nine criteria have entered into the corporate screening procedures
of many UN agencies, including WHO.
The Global Compact Office itself, however, does not assess corporations according
to these criteria before accepting them as Global Compact participants,74 a fact that
does not seem to be common knowledge within other UN agencies. Interviews and
statements by staff in other UN agencies suggest that many of them assume that the
companies participating in the Global Compact have been screened for their responsible
corporate behaviour and are thus acceptable partners requiring no further assessment.
This assumption may create further confusion in the future. It may also impinge
on the ability of international civil servants to refuse a joint project proposed with a
Global Compact corporate participant. One official in WHO’s Government and Private
Sector Relations Division, for example, refused to approve a joint project because
evaluation of the company’s proposed arrangement suggested corporate motives that
clearly contradicted WHO’s guidelines. His judgement was, at first, challenged on the
grounds that the corporation in question was a Global Compact participant. Further
developments proved his decision well founded.
The fact that the Global Compact does not scrutinize the actual practices of its
participant companies, yet still presents them as leading ‘corporate citizens’ has another
impact in the field of health (and in other social areas.) It provides companies with a
good image. Such an enhanced reputation can act as a shield or ‘goodwill bonus’
against the efforts of UN agencies, member states, citizen watchdogs and labour groups
to hold them accountable to the public for their actions, either through regulation or
through public naming-and-shaming.
The Global Compact’s acceptance of the infant food manufacturer, Nestlé, is a case
in point. The company is well known for persistently violating the International Code
of Marketing of Breast-milk Substitutes and subsequent related WHA resolutions and
for attempting to undermine its national implementation.75 According to UNICEF’s
73 In June 2004, corruption was added as tenth criterion
74 For details of the approval process, see, for example, Zammit 2003: 79. For the latest acceptance
conditions, see the Global Compact’s website: www.unglobalcompact.org.
75 See, for instance, IBFAN/ICDC 2004; Richter 2001.

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING 67
corporate screening criteria, Nestlé is not eligible for alliances with the agency because
of these practices. Yet the Global Compact not only accepted Nestlé’s participation,
but also singled out and praised its socially responsible labour practices. Global Compact
Executive Head Georg Kell dismissed concerns about the negative impact that Nestlé’s
acceptance could be predicted to have on work to prevent harm to children’s health
and lives. He described such concerns as a ‘single-issue’ in contrast to the Global
Compact’s much broader aims (Richter 2003b: 44–45).
These few examples show that safeguarding public interests in the field of health
needs a more thorough examination of the guidelines and actual procedures of other
UN agencies besides those of WHO. It also requires a thorough evaluation of legally
independent global public-private partnerships. An investigation should examine
whether restructuring the decision-making arrangements of these social experiment
initiatives or abandoning them altogether may, in fact, be the best way to safeguard
public interests and to preserve the integrity of scientific and democratic processes.

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING
68
4. Building safeguards for public-private
interactions: The wider context
The major obstacle to clarifying and instituting public interest safeguards seems to be
political rather than theoretical or technical. It is unlikely, therefore, that meaningful
and effective safeguards can be fostered unless the frameworks of thought that have
favoured the emergence and continued dominance of the public-private ‘partnership’
policy paradigm in the international health arena, and the push and pull factors that
have supported them, are taken into account.
The rise of the partnership paradigm within the UN
Five factors
Five major intersecting factors emerge from the histories of public-private ‘partnerships’
involving the UN and WHO:76
1. Financial pressures on the UN, its agencies and programmes;
2. A shift of the dominant development model from that of the New International
Economic Order (NIEO) to Washington consensus-based models;77
3. UN leaders who favoured the neo-liberal restructuring of the UN;
4. Major transnational corporations recognising that collaborating with the UN
could help them gain markets and political influence and could ward off pressure
from UN member states and social movements critical of an ‘unfair globalisation’;
and
5. Hopes raised by some large-scale private donations, in particular by the venture
philanthropy donations of media magnate Ted Turner and Microsoft founder
Bill Gates.
The 1992 Rio de Janeiro Earth Summit
The beginning of the UN trend towards closer policy relationships with big business
is often set at 1992 when the UN held its Conference on the Environment and
76 See, for instance,Tesner with Kell 2000; Bruno and Karliner 2002; Zammit 2003: 28–36; Buse and
Walt 2000a; Buse and Walt 2002b
77 For more information on these models, see, for instance, Emmerij et al. 2001.

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING 69
Development (UNCED), dubbed the ‘Earth Summit’, in Rio de Janeiro.78 Until then,
transnational corporations and their business associations had often taken a stand
against the work of UN agencies. Their stand had been particularly pronounced in the
1970s and early 1980s when UN agencies were striving to fulfil their mandate to work
for redistributive social justice policies under the New International Economic Order
framework. This mandate included drawing up a UN Code of Conduct for
transnational corporations and advocating the transfer of resources and technology
from North to South.
In 1992, however, a few years after developing countries had lost the little influence
they had in international politics because of geopolitical changes following the end of
the Cold War and the effects of the debt crisis, work on this UN Code was abandoned.
Author Sandrine Tesner describes the UN’s abandoning this Code, even though
negotiations had resulted in a text such that adoption was within reach, as an attempt
to quell any lingering private sector “suspicion” about the organisation because of its
work towards a New International Economic Order (Tesner with Kell 2000: 22-23).
The demise of the UN Code came shortly after influential business associations
such as the International Chamber of Commerce (ICC) and the newly formed World
Business Council for Sustainable Development (WBCSD) had mounted a massive
publicity campaign at the Earth Summit. A WBCSD publication, Changing Course,
set the tone. It presented the combination of free markets, free flows of foreign direct
investment and ‘voluntary’ corporate social responsibility as the best way to achieve
sustainable development. Public, binding regulation of corporate practices was presented
as anti-industry and a needless waste of public resources (Bruno and Karliner 2002:
22–32).
Resistance against regulation of transnational business
This industry strategy was nothing new. WHO, like other UN agencies, had often
had to withstand pressure from industry and from its major financial contributor, the
United States, whenever it proposed regulating products or practices of transnational
corporations that were harmful for health. In 1981, for instance, the World Health
78 For example, a report by the UN’s Joint Inspection Unit marks the Earth Summit as a “turning
point” in “bringing the private sector into policy formation.” The Agenda 21 resulting from the Earth
Summit introduced a new form of UN interlocutors, nine Major Groups, which included business as a
category. The report of the UN’s Joint Inspection Unit notes that the Commission on Sustainable
Development experimented with a new form of participation, “multi-stakeholder dialogues,” to allow
business and industry (on a par with other societal actors) to contribute to strategies and policies for
sustainable development (Mezzalama and Ouedraogo 1999: 12).

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING
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Assembly had adopted the International Code of Marketing of Breast-milk Substitutes.
The International Federation of Pharmaceutical Manufacturers Associations (IFPMA)
(some of whose members were also infant food manufacturers) regarded this code as
the result of tactical mistakes. They vowed to make sure that there was no similar
international regulation of transnational pharmaceutical practices. Their efforts included
enlisting the support of industrial countries against what they depicted as the illegitimate
attempts of WHO to act as a ‘supranational’ regulatory body.79 In the mid-1980s, the
US State Department emphasized its:
“strong position that the World Health Organization should not be involved in
efforts to regulate or control the commercial practices of private industry, even
when the products may relate to concerns about health. This is our view regarding
infant food products, and pharmaceuticals, and tobacco and alcohol.” (quoted in
Chetley 1990: 92)
In 1986 and 1987, when WHO tried to produce some Ethical Criteria for Medicinal
Drug Promotion, the United States withheld a large part of its contribution to the
Organization. The US started paying some of its arrears only after an 1988 editorial in
Science, an influential international journal, pointed out that it was unfair to withhold
$118 million, nearly one-quarter of WHO’s budget, when one of WHO’s achievements
– the eradication of smallpox – saved the United States $110 million in vaccination
costs each year (Chetley 1990: 120–1).
The United Nations faced a similar situation. Even though it had gradually been
moving away from ideas underpinning the New International Economic Order since
the 1980s and even though it had come to accept business as a regular interlocutor, for
example, in its Commission of Sustainable Development, the UN continued to be
subject to depictions promulgated by conservative think-tanks as being an anti free
market, inefficient and expensive organization. In 1997, it was brought to the brink of
bankruptcy because the US deliberately withheld $1.5 billion in contributions in order
to bring about reforms within the UN.80
79 See Richter 2001: 92–94; Chetley 1990: 69–93.
80 For more information, see Zammit 2003: 41–47. The total 1996 UN budget contribution from the
US, including assessed and voluntary contributions, of US$ 4.5 billon amounted to less than the combined
costs of New York City’s Fire and Police Department (South Centre 1997).

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING 71
Reform of the United Nations
These long-standing pressures on the United Nations combined with the election of
Kofi Annan as the new UN Secretary-General in December 1996 led to the
institutionalisation of the ‘partnership with industry’ model within the UN system as
part of Annan’s UN reform. As a 1999 report by the UN’s Joint Inspection Unit put it,
“the strong leadership of the Secretary-General … and his expressed conviction that
the goals of the United Nations and the private sector can be mutually supportive has
given additional momentum to a rapprochement made necessary by changes in the
global environment” (Mezzalama and Ouedraogo 1999: 5).
Several commentators regard 1997 as the ‘turning point’ of UN-business relations.
It was in July of that year that Annan:
“unveiled a long-awaited reform proposal that was the result of a team headed by
Maurice Strong . . . former CEO of several large corporations, who had headed the
preparations of the Rio Conference a few years earlier. While the report did not
devote a specific section to the UN-business relationships, it emphasized the role
of civil society as not only a disseminator of information or provider of services but
also as a shaper of policy. Civil society referred to nongovernmental organisations,
academic and research institutions, parliamentarians, and corporations. Indeed the
report stated openly that the relationship of the UN system with the business
community was ‘of particular importance’.” (Tesner with Kell 2000: 33)81
A few months later, in January 1998, the UN Secretary-General delivered a speech at
the World Economic Forum (WEF) in Davos, Switzerland, where he spoke about a
“fundamental shift” within the United Nations. He said that the UN recognized that
peace and prosperity could not be achieved without ‘partnerships’ between various
sectors in society, including business. He added that while the UN and business
community were “still overcoming a legacy of suspicion” of each other, they could
“bridge these differences and turn what had been fledging arrangements of cooperation
into an even stronger force” (quoted in Mezzalama and Ouedraogo 1999: 5).
High hopes that the new partnership paradigm would replenish the UN’s financial
coffers were raised in September 1997, when Time Warner vice-chair and CNN founder
Ted Turner donated US$1 billion to the UN via his new philanthropic UN Foundation
– even though the private sector immediately indicated that they did not want to see
partnership with the UN primarily in terms of donating funds (Tesner with Kell,
2000: 35; 89).
81 This statement exemplifies confused terminology as well as the privileged status of the private sector.

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING
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Talks with industry
Regular attendance of UN leaders at the annual World Economic Forum and other
business fora has been a feature of the new partnership paradigm ever since.
Talks between the UN Secretary-General, UN senior staff and leaders of the
International Chamber of Commerce have led to several statements outlining the
potential for the goals of the UN and of business to be mutually supportive. These
statements emphasized how the UN can give business a greater role in setting global
rules and thereby create ‘win-win’ situations, or what the Secretary-General later called
a ‘globalisation with a human face’.82
In September 1998, for instance, the International Chamber of Commerce (ICC)
held a Business Roundtable Dialogue in Geneva, a continuation of talks initiated by
Kofi Annan in 1997. It brought together Chief Executive Officers (CEOs) of 450
companies, and leading figures from UN agencies, the World Trade Organization and
the World Bank. According to Helmut Maucher, then ICC president and Nestlé CEO,
the Geneva dialogue was convened in order “to bring together the heads of international
companies and international organizations, so that business experience and expertise
is channelled into the decision making process for the global economy” (quoted in
Balanyá, Doherty et al. 2000: 167).
The visible outcome for those who had not been invited to this closed meeting was
the Geneva Business Declaration, which indicates how industry saw the role in global
decision-making not only of business but also of other societal actors. For example, it
advocated attributing ‘additional authority’ to intergovernmental organizations but
only “with the proviso that they must pay closer attention to the contribution of
business and competition to wealth creation [and] recognize the need for less
bureaucracy”. ‘Lean’ and ‘strong’ governments should reshape rules in ways that promote
transnational business and flow of finances. Industry leaders warned governments,
however, not to confuse ‘strong’ with “economic nationalism” because this would be
“out of step with the realities of the global economy” (ICC 1998).83
The Geneva Business Declaration also outlined how a “diffuse but virulent
globophobia” should be “opposed” by improving citizen understanding of globalisation
and its impact. ICC member companies accepted that citizens may voice their concerns
about the uncertainties created by economic globalisation, but their Declaration sowed
82 For some of the important early policy discussions at the World Economic Forum and in discussions
with the ICC, see, for example, Tesner with Kell 2000: 31–37. For a more critical account, see, for
instance, “The corporate cooptation of the United Nations” in Balanyá, Doherty et al. 2000: 166–174.
83 Points 5.1. and 6.4.

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING 73
the seeds of distrust towards “activist pressures groups”. Their emergence, it claimed,
“risks weakening the effectiveness of public rules, legitimate institutions and democratic
processes.” The business leaders suggested establishing rules defining the ‘rights’ and
‘responsibilities’ of ‘activist’ groups if they did not take steps to improve internal
democracy, transparency and accountability (ICC 1998).84
Business interest in UN partnerships
The beginnings of the UN-business partnership paradigm not only coincide with a
severe funding crisis within the UN but also with growing industry concerns about
financial instability triggered by the collapse of the Mexican economy in 1994 and
then by financial crises in several Asian countries in 1997. Business leaders concluded
from these shocks that wholly unregulated markets were not, in fact, good for
international business and finance. In the words of the Geneva Business Declaration, “a
key challenge in the context of a rules-based freedom for business is to prevent financial
meltdowns and maintain a stable international financial system.”85 Moreover, in the
late 1990s, corporations were growing increasingly concerned about the resistance of
some states and citizen movements to global neo-liberal restructuring. Several of them
had worked against the proposed Multilateral Agreement of Investment (MAI) that
would have given rights to transnational corporations equal to and even above those
of nation states. A focus of this resistance was to prevent the extension of unfair global
trade agreements, resistance that became most visible at the World Trade Organization’s
bi-annual Ministerial Meeting in Seattle, USA, at the end of 1999.
Against this backdrop, an arrangement seems to have been reached between the
UN and big business. If UN leaders tried to reshape their organisations in ways
conducive to a business friendly climate, to involve business leaders still further in
global policy debates, and to help them deal with activist movements and organisations,
then business associations would help to turn back the tide of sentiment against the
UN within the business community and relevant government circles, particularly in
the United States. This agreement is reflected in the Global Compact, which is often
presented as the flagship UN-business partnership, a kind of ‘social contract’ that will
safeguard and promote both public and private interests in a globalising world.
84 Points 4.1 and 6.3 and conclusion 4.
85 Point 4.3.

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING
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The Global Compact
The Global Compact was first presented by UN Secretary-General Kofi Annan in
January 1999 at the World Economic Forum in Davos, Switzerland. He challenged
companies to integrate nine universally accepted principles from the fields of human
rights, labour rights and environmental protection into their business practices. In
return, UN organisations would work for open global markets and help companies
‘dialogue’ with their critics (Annan 1999).
Although the arrangement has since been formalized under a Global Compact
Office, there are still no meaningful Global Compact internal mechanisms for assessing
whether the participating companies engage in harmful practices. The anticipated
social benefits derived from what was assumed to be a noticeable improvement in
corporate practices by their adherence to the nine selected ethical principles remain
unproven.86
For the corporations involved, however, the Global Compact arrangement has
arguably brought great benefits. It can be seen as one of the most cost-effective ways of
improving tarnished corporate images by what has been termed ‘bluewashing’ – image
transfer by being associated with the UN flag.87 The Global Compact has lent itself to
corporate undermining of more comprehensive and possibly binding international
human rights regulation of transnational corporations because corporations now argue
that such regulation goes against the spirit of the Secretary-General’s ‘voluntary’ Global
Compact.88 89 The Global Compact helps to increase the influence and spread of
86 In 2002, UNRISD project coordinator Peter Utting concluded in his review of regulation via ‘multi-
stakeholder initiatives’ that “the Global Compact still needs to prove its ability to force the pace of
corporate reform” (Utting 2002: 90). Recently, the Global Compact Office commissioned a review of
the Global Compact’s impact from the business consultancy firm, McKinsey&Company, in preparation
for the Global Compact Leaders’ Summit in June 2004. This review did not assess the impact of
participation in the Global Compact on the corporations’ actual business practices in the areas of the
nine Global Compact principles. For more information on the review’s findings, for example, why
companies regard the Global Compact as an “entry-point to accessing the broader UN system” and why
it could come to “symbolize a powerful example of the potential of UN reform”, see McKinsey&Company
2004.
87 Term coined in Bruno and Karliner 2000.
88 For example, the International Chamber of Commerce (ICC) and the International Organization of
Employers (IOE) have expressed their opposition to the ‘binding and legalistic approach’ of the UN
Draft Norms on the Responsibilities of Transnational Corporations and other Business Enterprises with
Regard to Human Rights. They have described efforts towards more public international regulation of
transnational corporate practices as “counterproductive to the UN’s ongoing efforts to encourage
companies to support and observe human rights norms by participating in the Global Compact.” They
have said that the draft norms “risk inviting negative reaction from business, at a time when companies

PUBLIC-PRIVATE PARTNERSHIPS AND INTERNATIONAL HEALTH POLICY-MAKING 75
transnational corporations through fostering national mini-Global Compacts and
various partnership projects. It has also helped to draw distinctions between ‘radical
fringe elements’ of civil society (also termed ‘sharks’ and ‘orcas’) and those NGOs of
the 21st century that use market mechanisms to work for change (Sustainability 2003:
14; 50). It contributes to marginalising those advocacy groups and networks that are
critical of the Global Compact and other partnership arrangements that they regard as
inappropriately close relationships between public interest and commercial actors.90
The Global Compact can also be seen as an arrangement that marginalises the
wishes of many UN member states. The Global Compact was not initiated as a result
of a mandate from UN member states.91 In fact, when the UN Secretary-General
announced that he wanted to establish more formal consultations mechanisms between
the UN and business by creating a United Nations Enterprise Liaison Office, modelled
along the existing Non-Governmental Liaison Office, member states opposed the
proposal because they perceived it as a challenge to their sovereignty in policy-making
(Tesner with Kell 2000: 33).
UN member states hesitantly approved the Global Compact initiative only after it
had already been set up by the UN Secretary-General. But they qualified their approval
with the condition that the Global Compact should be not be regarded as a permanent
arrangement and that it should be formally evaluated some time later (Zammit 2003:
48).
The Report of the Secretary-General to the UN General Assembly in 2001, which
was instrumental in gaining more support from the UN member states for the Global
Compact, states: “to avoid potential conflicts of interest, the Global Compact does
not accept financial contributions from the private sector for its own operations” (UN
2001: 33).
are increasingly engaging into voluntary initiatives to promote responsible business conduct” (ICC/
IOE 2003).
89 Early on, the International Chamber of Commerce (ICC) had laid out its prime condition for
participating in the arrangement: “There must be no suggestion of hedging the Global Compact with
formal prescriptive rules. We would resist any tendency for this to happen” (ICC 2000). While opposing
binding regulation for potentially harmful corporate practices, the ICC was very much in favour of
binding and enforceable rules in other areas. When it signalled its support for the Global Compact, it
specified that, in return, the UN’s September 2000 Millenium Assembly should “ensure that the United
Nations takes the lead in supporting a rules-based open system of international trade and investment
while opposing all forms of protectionism” (quoted in New 2000).
90 For more information, see, for example, Zammit 2003: 29–104. For an account how the Global
Compact contributes to creating these distinctions in the NGO community, see pp.80–81.
91 For more information about the partnership paradigm being institutionalised before any discussion
with UN member states, see, for example, Ollila 2003c.

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The Global Compact Office seems to interpret this statement very loosely. To
replicate the Global Compact by setting up national, regional or industry-sector specific
Global Compact networks, the Global Compact website, under the heading ‘outreach
events’, gives the following advice: “Companies and other donors can be asked to
contribute to the costs of the outreach event” (UN 2003d). Once in place, running
such a network should not be difficult, because the website suggests putting in place “a
small secretariat funded by contributions of the network participants” (UN 2003c).
An example of this is the Symposium on the United Nations Global Compact and
Swiss Business, held in Switzerland in October 2002. The event was a Nestlé co-
funded launch of the Global Compact network in Switzerland and promoted Nestlé
as a socially responsible employer.92
Moreover, the Global Compact Office seems not to have seen any conflict between
its mandate and soliciting corporate funds for its The 21st Century NGO report and its
Executive Head promoting the publication as the Global Compact’s contribution to
the “high-level UN panel that is currently examining the interaction between civil
society and the UN system as a whole”.93
The rise of the partnership paradigm within WHO
A similar pattern can be seen in the international health arena. WHO’s regular budget
has been frozen since the early 1980s and member states’ assessed contributions have
declined despite the growing number of tasks facing the Organization.94
Strong support from above
A key factor in the exponential increase in WHO’s promotion of and involvement in
public-private partnerships was the election of Gro Harlem Brundtland in May 1998
as WHO Director-General. Dr. Brundtland had been a strong supporter of partnership
models ever since she had chaired the World Commission of Environment and
Development whose recommendations catalysed the 1992 Earth Summit. Back in
1990, she had asserted:
92 For more information, see Richter 2003b: 44–45.
93 The main corporate funders were Novo Nordisk, VanCity Savings Credit Union, Du Pont, Holcim
and the International Finance Corporation (Sustainability et al. 2003: 2).
94 See Box 2: ‘How donors call the shots’, in Yamey 2002b: 1108. See also DIFID 2002: 18; Ollila
2003c: 46.

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“Partnership is what is needed in today’s world, partnership between government
and industry, between producers and consumers, between the present and the future
. . . We need to build new coalitions . . . We must agree on a global agenda for the
management of change . . . We must continue to move from confrontation, through
dialogue to cooperation . . . Collective management of the global interdependence
is ... the only acceptable formula in the world of the 1990s.” (quoted in Lohmann
1990: 82)
As Prime Minister of Norway in the 1980s and 1990s, Dr. Brundtland had been a
promoter of Third Way politics. Immediately after her election as the WHO Director-
General, she began reshaping the agency along neoliberal lines reflecting the modified
Washington Consensus (with a human face) model95 and the Third Way thinking
exemplified by British Prime Minister Tony Blair’s New Labour party.
As Buse and Walt point out, the characterising feature of the UK Third Way model
is a form of “neocorporatism” in which a variety of social actors, including the private
sector, are regarded as ‘stakeholders’, all of whom are believed to have a legitimate say
in public policy making (Buse and Walt 2000b: 551).96 This corporatist view is also
95 The term Washington Consensus was coined by John Williamson, a senior fellow at the Institute for
International Economics and former World Bank staff member in 1993. It refers to one type of neoliberal
economic thinking which was elaborated in Washington, the site of the Bretton Woods institutions (the
International Monetary Fund and the World Bank), the US government, and conservative think tanks.
It’s prescriptions, known under the name structural adjustment policies, shaped development policy in
the 1980s and 1990s. A book on the history of ideas in the UN describes this first Washington Consensus
as “a recycled version of trickle-down economics, with growth given greater weight than income
distribution and social objectives. The underlying hypothesis was that policy reforms designed to achieve
efficiency and growth would also promote better living standards, especially for the poorest. The social
costs were [seen as] inconvenient and temporary.” It was only after resistance of many developing countries
and publication of UNICEF’s Adjustment with a Human Face (Giovanni et al. 1987) that these policy
prescriptions changed. UNICEF’s study argued that these social costs were not just unfortunate but
inevitable by-products of structural adjustment but that they could and should be avoided by putting
people, and in particular vulnerable groups in a country’s population, at the center of attention. (for
more information, see Emereij et al. 2001: 128–130) The Washington consensus II took some of these
concerns on board, for example, when advising to “invest” in health and education. Yet, it remains a
fundamental problem that Washington Consensus models continue to dominate development thinking
and policies and that they, more than ever, promote social engineering, for example by advocating
corporatist models of decision-making. Better alternatives are not given enough space neither in debate
nor in practice (See also Bøas and McNeill 2004: 224, fn. 9).
96 Buse and Walt point out that, as early as 1987, author G. Peters had described the corporatist nature
of what they call Global Public Private Partnerships as a form of third party government. See Buse and
Walt 2000b: 551.

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inherent in the global governance model that has made its way from the Bretton
Woods institutions (World Bank and the International Monetary Fund) into UN
politics.97 Its philosophy is ‘shared decision-making’, which is at the core of the UN’s
‘partnerships’ with industry. Its actual arrangements include financial relationships,
joint operational ventures, and policy interactions such as agenda-setting ‘multi-
stakeholder dialogues’ and roundtable discussions.
A new Corporate Strategy for WHO
In January 2000, Dr. Brundtland presented a new Corporate Strategy for the WHO
Secretariat to WHO’s Executive Board. This document emphasized the need to increase
the effectiveness of WHO’s work through “collective action and partnerships”. The
corporate strategy defined the new task of the Secretariat’s work as decreasing inequities
in health by “carefully negotiating partnerships and catalysing action on the part of
others.” It made “negotiating and sustaining national and global partnerships” into a
‘core function’ of the WHO Secretariat (WHO 1999a, para 5, 9, 15).
The document stressed that this emphasis should not be regarded as constituting a
change in WHO’s mission as set out in its Constitution, and that the Secretariat’s new
corporate strategy would continue “to reflect the values and principles articulated in
the Global Strategy for Health for All and reaffirmed by the 1998 World Health
Assembly” (WHO 1999a, para 8).
Shift away from Health for All
But many observers disagreed, saying that WHO was shifting away from its
constitutional mandate and from an approach informed by human rights and social
justice. As the roadmap for guiding WHO policy, Dr. Brundtland chose the World
Bank’s 1993 annual World Development Report, Investing in Health, which advised
governments to focus on cost-effective interventions rather than on strengthening
health care systems. Many of the Report’s authors were brought to WHO to establish
a new Evidence and Information for Policy unit. WHO, said one public health
academic, became “a branch of Harvard and the World Bank” (quoted in Yamey 2002b:
1110).
In the year 2000, there was no official reflection within WHO on the obstacles
that had stood in the way of achieving Health for All since the goal and strategy had
97 See, for example, Buse and Walt 2000b: 554. For a critique of neoliberal governance, see, for example,
Taylor 2004.

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been announced by WHO and UNICEF in 1978. Nor was there any reflection on
how to continue on the path as reaffirmed by member states in 1998. On the contrary,
according to one WHO official, Health for All was “censored” from WHO’s
headquarters language (quoted in Yamey 2002c: 1172).98 Some observers remark that
if it had not been for the Peoples’ Health Movement, founded in 1999, Health for All
may well have disappeared from the international public health agenda.
In January 2000, Dr. Brundtland established a Commission on Macroeconomics
and Health (CMH) and charged it with assessing the place of health in global economic
development. Several national governments and the private foundations of Bill and
Melinda Gates, and Ted Turner paid for its work. In December 2001, the Commission
presented its report Macroeconomics and Health: Investing in Health for Economic
Development (which has become known as the Sachs Report after the Commission’s
chair, economist Jeffrey Sachs). WHO’s Director-General translated it into a blueprint
for international health strategies (CMH 2001).
The Commission stated that one of its main achievements had been to turn around
the relationship between economic development and health. It still mentions that
people’s health is a “priority goal in its own right,” but emphasises the notion of “health
as a central input into economic development and poverty reduction” (CMH 2001).
The report stresses the benefits of what it described as new funding mechanisms,
namely the newly established Global Fund to Fight AIDS, Tuberculosis and Malaria
and other funds modelled along the lines of the GAVI alliance. It also called on the
pharmaceutical industry to “generalize the corporate principles” that were seen as the
basis of “highly laudable programs of drug donations and price discounts.” It promoted
the international pharmaceutical industry as a key player in voluntary and cooperative
arrangements with governments, donors and international organizations that would
enable poorer people to gain access to essential medicines “while protecting intellectual
property rights to the maximum extent”99 (See, for example, CMH 2001:19 goal 7;
and 14–15; 86–91).
The Commission recommended that WHO become the technical secretariat for
the Global Fund and dismissed WHO member states’ concerns about conflicts of
98 Health for All had become an “unfashionable, if not ‘dirty word’ in the 1990s,” says Kent Buse.
“Health for All was tied up with a political battle for equity and inclusion. In the 90’s health policy came
to reflect the prevailing ideology. An ideology which emphasized health systems reform – a market
oriented approach informed by economic tools and neoliberal values” (Yamey 2002c: 1172). For more
details, see also Ollila 2003a: 138–145.
99 Interestingly, patient and other action groups that have been instrumental in lobbying for lower
priced anti-retroviral drugs are not mentioned as indispensable partners in the alliances envisioned by
the Commission.

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interest in what the Commission presented as ‘more flexible working approaches’ (that
often include the private sector in decision-making positions on boards of the new
global health partnerships) as unnecessary constraints.
Soon after the Commission’s report was released, several articles in medical journals
and the general media expressed grave concerns about the proposed changes in the
international health arena. A lead article in Le Monde Diplomatique asked whether Dr.
Brundtland was promoting ‘Health for All or Riches for Some?’ It queried how Dr.
Brundtland could have endorsed drug patents in a speech at the World Economic
Forum in January 2001 when lower-income countries were still battling for access to
affordable antiretroviral drugs in the face of the WTO’s TRIPS agreement. Such
endorsement, it argued, could not be seen as support for countries such as South
Africa, which five weeks later was faced with a law suit from 40 major pharmaceutical
TNCs challenging the government’s proposed legislation to allow generic drugs to be
imported from other countries. The article expressed apprehension at WHO’s increasing
dependency on sponsors who could establish the rules of the game (Motchane 2002).
The editor of the respected and prestigious medical journal, The Lancet, Richard
Horton, initially indicated satisfaction with the high-profile promotion of the Sachs
report because he thought that the shift in policy approach advocated by the report
might attract more funding into the health arena. At the same time, however, Horton’s
editorial drew attention to problems caused by WHO’s proximity to certain industries.
He contrasted Dr. Brundtland’s relative silence on the social responsibilities and
problematic behaviour of pharmaceutical companies with her forceful public
condemnation of tobacco companies. He also highlighted the climate of censorship
developing within WHO and the Organization’s lack of openness to discussing differing
views and opinions about the changes and their impacts that the new management
had brought in (Horton 2002a: 1607).
A few months later, in September 2002, Horton raised the alarm when the UK,
WHO’s third largest extra-budgetary government donor, asked WHO to make its
“roles and mandates … consistent with the [UN’s] Millennium Development Goals.”
The request was an implicit demand that WHO refocus its activities towards supporting
the Global Fund and the UN Millenium Task Force on AIDS, malaria, tuberculosis
and access to essential drugs. The Lancet pointed out that such a shift could lead to
WHO neglecting other areas of its mission, such as supporting the development of
comprehensive health programmes and setting international norms and regulatory
standards. Horton concluded that the UK’s demand could well lead to a “damaging
reinterpretation” of WHO’s mandate (Horton 2002b).
By this time, it was clear that private sector donations were increasingly regarded as
important in the international health arena. When the Bill and Melinda Gates
Foundation donated US$750 million to set up the Global Alliance for Vaccines and

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Immunization (GAVI) in 1999, hopes soared of greater access to previously untapped
financial resources. Hopes were also raised when several major pharmaceutical
companies made high-profile drug donations and offered to reduce the prices of selected
pharmaceuticals.
No alternatives to partnerships with business?
A year before Dr. Brundtland stepped down from the post of WHO Director-General
in 2003, she reportedly indicated unease about legally independent global health
alliances in the context of WHO’s difficulties in ensuring its accountability to its
member states (Yamey 2002a, Buse 2002). Yet, at the same time, she continued to tell
member states that:
“In a world filled with complex health problems, WHO cannot solve them alone.
Governments cannot solve them alone. Nongovernmental organizations, the private
sector and Foundations cannot solve them alone. Only through new and innovative
partnerships can we make a difference. And the evidence shows we are. Whether we
like it or not, we are dependent on the partners ... to bridge the gap and achieve health
for all.” (Brundtland 2002a, emphasis added)
This assertion reinforced the impression that partnerships per se are part of well proven,
inherently positive, even unavoidable, policy model. But, as stated earlier, subsuming
such a range of interactions between public and private sector actors under the one
umbrella term ‘partnership’ obscures the fact that many of these interactions are not
fundamentally new. Re-naming all kinds of financial, policy and operational
relationships and collaborations as ‘partnerships’ hinders decision-makers and civil
servants from calling upon the hard-won knowledge and experience gained over many
years about which interactions are likely to be relatively unproblematic, which are
unproblematic as long as they are appropriately circumscribed, and which should be
not be pursued under any circumstances.
There is a need to recover more systematically this existing knowledge on public-
private interactions and to adapt and use it when assessing the various global public-
private interactions in the international health field. There is a need to probe deeper
into the added value, risks and costs of the newer ‘social experiment’ UN-partnerships.
Above all, there is a need to examine the extent to which promoting the ‘partnership-
with-the private sector’ paradigm conflicts with the core values and functions of WHO
and other UN agencies.

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Alternatives
The partnership paradigm is not a given, but is a result of a particular framework of
thought and constellation of power. Political choices about the future course of the
UN’s approach to interacting with business actors can and have to be made.
One alternative to the PPP model is based on looking at the issues in a different
way. It is based on the premise that the public and the private sector have different
mandates and roles. The following measures can help WHO to ensure due diligence
in these interactions:
•re-name public-private partnerships as public-private interactions or initiatives
(PPIs) or similar, less value-laden terms;
•identify the category and sub-categories100 of the interaction that best facilitates
identification of risks and conflicts of interest; and
•establish clear and effective institutional policies and measures that put the public
interest at the centre of all public-private interactions.
One of the prime conditions for developing better institutional policies on these public-
private interactions is to abandon the culture of censorship within WHO that currently
stifles debate on pros and cons of closer collaboration with the private sector, the
adequacy of existing safeguards, and the links between neoliberal economic ideology
and the worldwide restructuring of public institutions and policies.101
WHO today
Is a candid review of WHO’s approach to public-private ‘partnerships’ possible under
the Organization’s new leadership of Dr. Jong-wook Lee? When the British Medical
Journal interviewed all the candidates for WHO’s top job in early 2003, Dr. Lee said
he would be a “listening” Director-General. As a former director of WHO’s ‘Stop TB’
programme, he favoured cross-sectoral interactions. At the same time, he remarked
that public-private partnerships were a means, not an end in themselves. He recognized
the risk that groups with vested interests may want to use partnerships to skew WHO’s
normative functions and pointed to the need to elaborate clear rules to prevent this
from happening (Lee 2003).
100 Such as category: funding relationships, sub-category: drug donations. The Guidelines for Interaction
with Commercial Enterprises contain already a good guidance for certain categories.
101 Medical journalist Gavin Yamey advocated an open appraisal of global public-private partnerships
and the establishment of a sound WHO policy “that has come from a process of open discussion and
debate” (Yamey 2002a).

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The World Health Report 2003 outlined the new administration’s views and plans
for the future and emphasised the need to build a global health partnership. It states
emphatically that such a partnership must be based “not only on rigorous science but
also on a clear ethical vision”.
The Report reminds readers about the need to link partnership building to core
values underlying an overall ethical vision of public health. Specifically mentioned is
the WHO Constitution and the fact that it defined back in 1946 “the enjoyment of
the highest attainable standard of health” as a fundamental human right. This World
Health Report reiterates the close connection between health – understood as a “state
of complete physical, mental and social wellbeing” – and social justice, peace and
security. At the same time, however, the Report refers to the centrality of the Millenium
Development Goals in WHO’s agenda and indicates that WHO regards health as
both “a goal in itself and a key development input towards other goals” (all quotes
WHO 2003a: xiii, emphasis added).
Since Dr. Lee took office in July 2003, there is some indication that WHO has
started refocusing its work around the principles of Health for All. But as far as updating
and strengthening public interest safeguards in public private interactions is concerned,
interviews with UN officials indicate that this task has not figured among the new
Director-General’s priorities during his first year in office. In fact, disquiet was expressed
over the reduction of financial resources and staff working on these issues.
Establishing a clear institutional policy on public-private interactions and giving
guidance for WHO and member states officials on how to manage these interactions
appropriately is a complex and politically sensitive task. Yet the new WHO leadership
needs to face up to the challenge without delay in the interest of the health of the
peoples of this world.

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5. Conclusion: The tasks ahead
Since the late 1990s, the number and reach of global public-private interactions have
increased dramatically. Many of these interactions have been conducted under a new
framework of thought that turns the UN, governments, the commercial sector, and
other societal actors into ‘partners’ and regards ‘shared decision-making’ as a core
component of the interaction.
WHO has been forcefully promoting the public-private partnership paradigm since
1998. Have public interest safeguards in the international health policy arena kept
pace with this policy development? This study has focused on WHO as the UN’s
designated specialised agency for global health matters. It has also looked at safeguards
within a few other UN agencies to ascertain whether there is policy coherency among
the various UN agencies, funds and programmes to protect their general and specific
mandates and functions.
This study concludes that international civil servants, member states and NGOs
have been encouraged to engage more and more in interactions with commercial actors,
but the development of accompanying public interest safeguards has lagged far behind
and is nowhere near completion. One of the greatest challenges is to clarify the ethical