Engaging the private sector to deliver COVID-19

tools and achieve Health for All

What is public private dialogue

and its best practices?

Module 4
LEARNING OBJECTIVES

By the end of the module, participants should be able to

• define the attributes of public private dialogue in a health policy setting,
• explain the benefits and risks of a public private dialogue process, and
• describe the good practices that make public private dialogue effective.

INTRODUCTION

The COVID-19 pandemic has triggered a global surge in demand for health services that
threatens to overwhelm health systems in many low-and middle-income countries. Ministries of
health are looking to mobilize their private and civil society sectors as part of national efforts to
contain and mitigate the pandemic as well as roll out the COVID-19 vaccine.

However, several LMIC governments face several barriers to effective engagement. They
include mistrust between public and private sectors in health, different organizational structures
and incentives, lack of a forum or mechanism to bring together the sectors and lastly, limited
skills and experience on how to foster genuine and transparent dialogue. In many cases,
policymakers and private sector leaders don’t see the benefit of investing the time and energy in
public private dialogue, especially if they have previous experience in non-productive meetings.

To help LMIC governments overcome these barriers, the World Health Organization’s Health
Systems Governance and Financing Department has developed two videos and companion
briefs on public private dialogue. The video/ brief’s purpose is to assist health ministries to move
towards a more inclusive governance approach given the urgent need to harness private sector
and civil society to quickly roll-out the COVID-19 vaccine and other COVID-19 tolls.

The first brief aims to assist ministries of health to better understand the conditions under which
a public private dialogue (PPD) can succeed and what the necessary strategies are to sustain a
PPD process in a low- and middle-income country. The video focus on :
• Defining what is PPD in a health setting
• Presenting the benefits and risks of PPD
• Describing “good practices” in a PPD in health based on a literature review as well as
practitioner’s experience and

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 • Sharing the experience of a public private dialogue forum in Tanzania to demonstrate
how genuine and intentional PPD can lead to real policy change.

WHAT IS PUBLIC PRIVATE DIALOGUE

Definitions of PPD vary greatly with a wide range of terms used. Examples include “platform”,
“process”, “partnerships”, “committee”, “roundtable” and “deliberations”. Despite the different
terminology and forms, several common features bind these different concepts together:
• Participation of multiple public and private sector stakeholders
• Interaction via forums or “spaces” where participants can physically meet and
communicate
• Convening around common issues or problems that bringing the stakeholders together
• Negotiating, collective learning, problem-solving, and decision-making [1] [2]

A “genuine” and “true” public-private dialogue process will contain one or more of these
elements [3]. Box 1 offers a working definition for PPD in health.

Box 1. General definition of PPD

A PPD process encourages the public sector to regard
"PPDs are structured mechanisms – both
stakeholders like the private sector and civil society as equal temporary and permanent- anchored at the
partners and to become more transparent in their decision- highest practical level, coordinated by a light
secretariat, and aimed at facilitating a discovery
making and interactions with them. At the same time, a PPD process by involving a balanced range of public
and private sector actors in identifying, filtering,
process enables these same stakeholders to have “a seat at accelerating, implementing, and measuring
the table” in policy and other decision-making discussions. It sector-related policy reforms and actions." [10]

also pushes the private sector to take more responsibility in

representing sector-wide interests, and not those of individual entities. Finally, civil society
organizations can play an instrumental role in giving voice to health consumer’s needs and
perspective.

Public private dialogue comes in many forms. It can be structured or ad hoc, formal, and
informal, wide-ranging, or focused on a specific issue, permanent or time bound. PPD can be
initiated by governments, entrepreneurs, or third parties, such as international donor agencies.
Sometimes the process involves only a single group in the private sector or entails the
government interacting with a wide range of private sector entities through umbrella groups that
represent the full range of private sector actors.

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To-date, most examples of a PPD in health in developing countries have primarily been between
public and not-for-profit groups such as faith-based organizations and non-government
organizations. Relatively little has been done to systematically include the for-profit private
sector in policy and planning through a dialogue process. And few civil society organizations are
routinely included in PPD.

BENEFITS AND RISKS IN PUBLIC PRIVATE DIALOGUE

While a formal PPD process can have an immediate effect on increasing and improving
interactions between public, private, and civil society groups, the same process can yield a
deeper and more long-term impact. Here are a few of the many benefits of investing in public
private dialogue.

Benefits

Better diagnosis and policy design. Including private sector and civil society through a PPD
process improves policy design and implementation by recognizing each stakeholder group’s
qualities and competencies and finding ways to harness them for the common good. Including
private actors in policy design also leads to more realistic and workable policy reforms by
incorporating all health sector partners’ perspectives and constraints. Increasingly, low- and
middle-income governments are placing greater importance on participation and dialogue to
bolster legitimacy, foster transparency, and strengthen accountability.

Better understanding of a health ministry’s reform objective. Including private sector in health
and civil society in policy or program design leads to these stakeholders’ better understanding
of the government’s intent and fosters private sector in health and civil society buy-in to its
implementation.

Removes implementation bottlenecks. Providing the private sector in health and civil society key
roles in the policy and planning process through a PPD process increases the likelihood that
both groups will accept and put the reforms into practice.

More predictable business environment. Establishing policies, regulations and health plans
through a transparent and participatory process enables private sector stakeholders to make

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investments in the health system based on long-term returns and sustainable initiatives rather
than temporary measures.

Mitigates risk. Frequent and consistent communication and sharing information with private
sector and civil society groups during design and implementation enables governments to be
better prepared for, manage conflicts, and troubleshoot problems as they arise.

Builds trust. Getting to know each other through frequent interactions fosters relationships
needed for trust between the public and private sectors. Trust is a core ingredient to achieve
any policy reform and/or program objective such as accelerating the rollout of the COVID-19
vaccine.

Risks

As in any political process, there are risks for all groups involved in a collaborative process like
PPD. If done poorly, a PPD process can not only waste resources, but it can worsen the
problem it is intended to solve. Common risks include:

Cherry picking of private sector favorites is common problem. Government officials often have
long-standing relationships with certain private sector individual and/or groups in the health
sector. PPD can reinforce vested interests and cronyism, give undue influence on certain
private sector individuals and/or groups, and provide a veneer of legitimacy for bad policies.
Similarly, the private sector can also abuse this privileged relations if they represent their own
interest instead of those of the private sector as a whole.

Over or under representation of public and private sector groups is another risk. Private sector
and civil society groups in most LMICs are not well organized, making it difficult to select truly
representative organizations to participate in PPD and can run the risk of under representation.
Or government entities may invite many more public officials creating a problem of
overrepresentation.

The most common risk of a PPD process is becoming a “talk shop”. If poorly planned and
unfocused, PPD can devolve into a process that does not achieve results or actions.
Participants become disillusioned, disengaged and the process eventually loses credibility.

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Building the public private dialogue process too closely around an individual creates significant
risk, such as becoming a “one person” show or losing steam when the individual become less
involved.

PPD can also become monopolized by a small group of powerful businesses that are often in
control of key resources and have crucial influence on government. If not careful, the process
can become a façade and screen for collusion, corruption, and captured interests.

Another common risk is the process becomes politicized, making it difficult to keep the process
politically neutral.

Although there are many risk factors that can derail a PPD process, awareness of the proper
procedures and careful planning can help mitigate these potential pitfalls. There are several
“good practices” as well as new competencies and skills that can help a ministry of health
mitigate the potential dangers. Indeed, establishing transparent ground rules, paying attention
to partners’ behavior, and careful planning can head off these risks before they arise.

“GOOD” PRACTICES IN PUBLIC PRIVATE DIALOGUE

Collaboration between public and private sectors is not a new concept. The social sectors are
filled with examples of advocacy coalitions, partnerships, and social networks. In the health
sector, they take on the forms of public-private partnerships, multi-stakeholder initiatives, and
coordinating mechanisms. What distinguishes a public private dialogue process from these
collaborative efforts is its focus on collective actions and impact.

Emerging experience reveals that public private dialogue in health share similar characteristics
and good practices with those of the other social sectors. Table 1 illustrates the eight good
practices based on the fields of public participation in governance, public-private dialogue in
other development sectors, policy advocacy and strategic communication in health [4] [5]. [6]

Table 1. Good practices in public private dialogue

1 Balanced Balancing the number of representatives from different partner
representation groups to fairly characterize the different sectors in health

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 2 Core leadership Leading by a small group of champions from public, private,
group and civil society groups who “own” and “drive” the PPD
process forward
3 Aligned vision Agreeing on a shared vision based on a common
understanding of the problem and aligning partners to a
consensus-driven mandate
4 Accountability Using data to make decisions, inform the PPD process,
through shared demonstrate visible results, and hold partners accountable for
metrics their actions
5 Organized structure Creating a formal structure to support participation and foster
cooperation with skills and resources to manage the day-to-
day operations of a PPD
6 Mutually reinforcing Leveraging individual partner’s capacity and expertise to
activities harness the collective action of public, and private partners to
achieve a common purpose
7 Honest broker Liaising with public, private, and civil society partners to
facilitate a shared vision, foster trust and resolve conflict while
providing focus and direction to the PPD process
8 Enabled partners Empowering partners with competencies, structures, and
resources to be effective participants in a PPD process

1. Balanced representation and active cooperation. PPD is based on the basic tenets of
partnerships - equity, transparency and shared risks and benefits [7] Achieving “mutual
benefit” is not easy, but it is a necessary condition for a successful PPD initiative [8]. Tactics
to foster balanced representation centers on creating policies and putting in place
procedures. Tasks include: (1) spending time to analyze stakeholders’ interest in and
capacity to participate in a dialogue process, (2) establishing transparent criteria by which
to select public, private and civil society actors, (3) defining terms for “joint decision making”
and (4) all PPD partners demonstrating commitment to the process [3].

2. Shared leadership by a small group of champions from both private and public sectors. PPD
does not happen unless someone really wants it to. A common hallmark of successful PPD
is a small group of strong and effective champions from multiple sectors driving the process
forward [8]The small group of champions have a wider view of the sector and places the
sector’s best interest ahead of his/hers. Important characteristics of the core group of

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 champions include: (1) seniority and influence, (2) commitment, (3) balanced
representation, and (4) a small and agile number.

3. Shared vision is essential to align partners with diverse organizational mandates to a

consensus-driven mandate. A successful PPD process requires all dialogue partners to
share a vision for change based on a common understanding of the problem and a joint
approach to solving it [9]This shared agenda, if authentic, creates intentionality and enables
all PPD partners “see” solutions and resources through similar eyes [9] In addition to
establishing a shared vision, creating norms and practices to guide how the dialogue
partners will work together is a critical step to aligning partner organizations. An effective
dialogue process requires that partners discuss these differences before starting on the
journey together. Steps to facilitate a better understanding include: (1) using a stakeholder
analysis to create awareness of each other’s different goals and perspectives, (2) facilitating
a frank discussion among partners to acknowledge each group’s autonomy and
interdependence, (3) brainstorming to establish the norms and practices, and (4) co-
developing a common vision of the problem and consensus on the solution.

4. Accountability through shared metrics. Agreement on a common agenda is illusive without

agreement on the way success will be measured and reported [9] [4]. Collecting data and
measuring results consistently on a short list of indicators across the public, private and civil
society groups not only ensures that all the partners remain aligned, but it also enables the
partners to hold each other accountable and to learn from each other’s successes and
failures. It also establishes a common language and becomes a platform for ongoing
learning that gradually increases the effectiveness of the PPD process. The key is to keep it
simple. Also, a system to monitor the shared metrics does not have to be complicated.

5. Formal, resourced structure. Most collaborative processes that fail – fail because they did
not mobilize resources to put in place a structure to support the day-to-day mechanics of a
PPD process. There is no “one-size-fits-all” structure for a successful dialogue process.
Experience shows, however, that facilitating an inclusive process with multiple stakeholder
groups requires a simple organizational structure that serves as the “backbone” for the
initiative [9]Coordination and constant communication take time which many of the dialogue
partners do not have. An organizational design operating under the umbrella of a secretariat
can effectively integrate a large number of stakeholders, constructively bring in expertise as
needed, and help ensure a coherent approach to PPD [4]

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6. Mutually reinforcing activities. The power of a collaborative initiative is not in the number of
partners but the coordination and reinforcement of their collective activities to achieve a
common purpose. A public private dialogue initiative depends on a diverse group of
stakeholders working together, leveraging each groups’ capacity and expertise to undertake
a specific set of activities while coordinating all the partners’ actions. Each stakeholder
groups’ efforts must fit into an overarching plan comprised of mutually reinforcing activities.
In a collaborative process, each stakeholder group is free to chart its own course consistent
with the shared agenda and informed by the shared metrics measuring success. Mutually
reinforcing activities become very clear once the work of many different organizations can
be mapped out against the same set of indicators.

7. Honest broker. A third party, like an honest broker is instrumental in “breaking” old habits to
model new behaviors that build trust while providing focus and direction to the process. An
outside honest broker can help jump start the PPD process as well as direct and sustain its
momentum to avoid becoming a “talk shop”. In many instances, this task falls to an
individual or group of individuals who intuitively and informally “lead” the process. Ideally, the
honest broker is someone who can genuinely claim to have experience in both the public
and private sectors and, of course, has local knowledge. Often the broker is either a local or
an international consultant. An effective honest broker possesses a combination of concrete
technical skills, balanced with special interpersonal skills [6].

8. Capacitated partners. Collaborative initiatives like PPD that fail to develop and internalize
these skills will fall short of reaching their full potential [6]. Many public, private and civil
society leaders have critical technical skills that have helped them succeed in their
respective professions. However, genuine dialogue also requires new technical
competencies and a range of personal skills – some that come naturally and others that may
need to be acquired [4] [10] [3](See PPD video #2 for an in-depth description.) Learning
these new skills and practicing them is one of the incentives to attract and retain busy
professionals in a PPD.

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TANZANIA COUNTRY EXAMPLE

The creation of the Public Private Dialogue Forum in Tanzania is a good example of a PPD
process and highlights many of the “good practices” discussed above. Tanzania has a long
tradition of participatory processes in different aspects of political, social, and economic life. The
health sector is no exception. There are several examples of how the Ministry of Health and
Social Welfare includes non-public actors ranging from community- and faith-based groups, and
more recently, private for-profit providers in routine policy and planning activities such as the
Joint Annual Health Sector Technical Review meetings and the bottom-up budget planning by
Council Health Management Teams. Despite these inclusive initiatives, a 2015 Private Sector
Assessment (PSA) recommended forming a PPD platform to ensure year-round and more
formal interactions between stakeholder groups on health issues. The German Development
Agency (GIZ), and later Danish International Development Agency (DANIDA), provided funds
and technical assistance to a small core group of public and private “champions” to form a
multi-stakeholder platform.

Step #1: Build foundation. A small group (approximately 8) of public, private and donor
representatives met informally on a weekly basis to coordinate development partner projects.
This representative group of champions quickly emerged as the leadership group for this public-
private initiative. This leadership group conducted a comprehensive stakeholder analysis to
identify who should become founding members and concluded there were too many public
sector entities between national and decentralized levels as well as private sector organizations
(e.g., 36 professional associations alone). The group charged the public and private sector
leaders to go back to their constituents to consolidate and select who will represent them. The
leadership group gave them strict guidance on how many they could select. The leadership
group also added civil society and advocacy groups to create balanced representation.

Step #2: Set the rules. The leadership group invited the newly selected representative
organizations to several meetings to agree on how they will work together. During the first two
meetings, they agreed on: (i) the PPD’s vision and purpose, (ii) the name Public Private Health
Forum-Tanzania (commonly referred to as the Forum), (iii) an organizational structure, (iv) a set
meeting schedule (e.g., once monthly and an annual retreat) and (iv) “code of conduct” which
all the founding member institutions signed.

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Step #3: Formalize the process. In subsequent meetings, the leadership group formed the
Forum’s governance structure and functions as well as established a “board” comprised of 15
organizations balanced across the three stakeholder groups. They also defined the Board’s
structure, and elected leaders from private, public, and civil society groups. Eventually, many of
the original champions were elected to the Forum Board of Directors and continued to play a
leadership role but in a more formal capacity. Also, the Forum Board members carried out
multiple meetings to get to know each other by sharing each organizations’ goals and
perspectives. The Forum’s board members also dedicated several months to raise funds from
its members, such as office space and equipment at one of non-profits, and donor funds to hire
secretariat staff and carry out activities.

Resources to fund a secretariat was a constant problem. DANIDA provided funds for an “honest
broker” to facilitate the Forum creation and institutionalization and build capacity in PPD skills.
All Board members supported the Forum – mostly in-kind contributions such as staff time, office
space, meeting expenses. Gradually, Forum board members started to pay “membership
dues”. But this was still insufficient to support a full-time secretariat or to cover the cost of the
annual forum event. Eventually donors and ministry of health stepped in to fund the Annual
Forum.

Step #4: Set direction. The Forum’s board used the 2015 PSA to consensus on the policy
challenges they would address and map the potential role of private sector relevant to the
priority challenges. The Board agreed on the Forum’s focus (shared vision) - policy changes
needed to create partnerships with the private sector to accelerate achievement of Tanzania’s
UHC Strategy. At the first Annual Forum, the over 250 stakeholders discussed the policy
agenda and priorities and voted on it. The agenda became the Forum’s strategy and work plan
for its first year. Data from the 2015 PSA also played a critical role in “depoliticizing” the
dialogue and informing the deliberations at the Annual Forum. Each year, stakeholder reviewed
and updated the policy agenda and Forum activities.

Step #5: Orchestrate partners. The monthly meetings helped institutionalize working
relationships between the different sectors in health. At the Annual Forum, the participants
formed working groups to co-implement specific tasks, like drafting policy briefs on private
sector role in UHC and on contracting private sector in essential services, creating district-level
Public Private Health Forum, and fundraising. The Forum’s Board also held annual one day
retreats to reflect on lessons from the year’s successes and failures and made several mid-

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course changes as needed. Due to resource constraints, much time was spent at the retreats
discussing fund raising strategies.

Step #6: Decide the future. Funding continues to be a constant struggle for the Forum. In fact,
there were times that the Board discussed disbanding the Forum. Yet to Forum continues to this
date and has managed to achieve several achievements: (i) elevating partnerships on the health
minister’s agenda, (ii) promoting two health partnerships still in effect today (Service Level
Agreements and National Health Insurance Fund reimbursement of accredited drug dispensing
outlet (ADDOs) drugs),(iii) establishing Forums at the district level that help the MoH establish
health priorities, decide on budget allocations and promote coordination of public and private
services and resources, and (iv) lastly, building trust and facilitating greater communication and
interaction on a wide range of policy and program initiatives supporting UHC.

CONCLUSION

This brief has provided a definition for PPD dialogue, given insights on the benefits and risks of
facilitating a dialogue process and described good practices needed to ensure PPD will be
effective and productive. The Tanzania example illustrates how PPD can unfold in a country
setting and assist governments to work with private sector and civil society to achieve a
common purpose.

REFERENCES

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