Health Public-private Partnerships Research Articles

A ‘Common Sense’ Response to Health Inequalities in Peru? Public-Private Partnerships in Health and the Implications for the Right to Health and Economic Inequality

Abstract Drawing on the case of Peru, our analysis looks at the ways in which the mainstream media creates support for government policies aimed at implementing Public-Private Partnerships (PPPs) in the health sector. Peru has a highly fragmented and segmented healthcare system, and the COVID-19 pandemic exposed the deeply embedded inequalities in accessing healthcare across the country. Nevertheless, the construction of hospitals financed and managed via a PPP arrangement has been one of the major solutions proposed and implemented by successive Peruvian governments in response to the health sector’s challenges. As our analysis demonstrates, the media has played a significant role in promoting this ‘common sense’ agenda whereby greater reliance on the private sector is presented as a solution to the weaknesses of the public sector. Our article considers the wider evidence on the role of PPPs in the health sector and contends that there is very little evidence on the system-wide benefits of PPPs, thus raising significant concerns about their ability to address health inequalities effectively. It also raises important questions about how far PPPs are able to support states in guaranteeing the right to health for their citizens.

Financing Public Health Expenditure in an Aging Society: The Role of Public-Private Partnerships in Health

Financing public spending on health is a challenge in an aging society. One option may be the Public-Private Partnership (PPP), which carries out long-term initiatives of great social importance. Health, very relevant to society, integrates Brazilian public accounts and is supported by the Unified Health System – SUS. The growing and significant aging of the population has been demanding more health services, with an impact on the SUS. The balance of the country's finances reinforces the need to resolve the public deficit, a situation that has afflicted Brazil for decades. The resumption of tax benefits, other financing opportunities and the reduction of tax expenditures are possible advantages of adopting PPPs, since the internalization of the proposal can be a potential gain, as it will allow investment to be deconcentrated from serving the poorest cities. populous to places less favored by the existing health network.

Quantitative decision making for investment in global health intervention trials: Case study of the NEWBORN study on emollient therapy in preterm infants in Kenya.

BackgroundPartners from an NGO, academia, industry and government applied a tool originating in the private sector – Quantitative Decision Making (QDM) – to rigorously assess whether to invest in testing a global health intervention. The proposed NEWBORN study was designed to assess whether topical emollient therapy with sunflower seed oil in infants with very low birthweight <1500 g in Kenya would result in a significant reduction in neonatal mortality compared to standard of care.MethodsThe QDM process consisted of prior elicitation, modelling of prior distributions, and simulations to assess Probability of Success (PoS) via assurance calculations. Expert opinion was elicited on the probability that emollient therapy with sunflower seed oil will have any measurable benefit on neonatal mortality based on available evidence. The distribution of effect sizes was modelled and trial data simulated using Statistical Analysis System to obtain the overall assurance which represents the PoS for the planned study. A decision-making framework was then applied to characterise the ability of the study to meet pre-selected decision-making endpoints.ResultsThere was a 47% chance of a positive outcome (defined as a significant relative reduction in mortality of ≥15%), a 45% chance of a negative outcome (defined as a significant relative reduction in mortality <10%), and an 8% chance of ending in the consider zone (ie, a mortality reduction of 10 to <15%) for infants <1500 g.ConclusionsQDM is a novel tool from industry which has utility for prioritisation of investments in global health, complementing existing tools [eg, Child Health and Nutrition Research Initiative]. Results from application of QDM to the NEWBORN study suggests that it has a high probability of producing clear results. Findings encourage future formation of public-private partnerships for health.

Gestión hospitalaria de un modelo de asociaciones público privadas y un modelo tradicional en dos hospitales del Callao

Introduction: The Peruvian health system usually has deciencies, This is how, since 2008, we have worked on the model of Public-Private Partnerships in Health (PPP), which seeks the best performance of the health system before being applied in the rest of similar hospital centers of the Peruvian health system. Objective: To compare the hospital management of a PPP model and a traditional model in two Essalud level II-2 hospitals. Methods: Mixed, non-experimental, and cross-sectional research carried out in two establishments, Hospital Alberto Barton Thompson (HABT) as PPP model and Hospital Luis Negreiros Vega (HLNV) as the traditional model, during the hospital management period from 2016 to 2018, six public officials and 150 external users. Hospital management was evaluated through hospital efficiency, nancial management, and user satisfaction. Results: In-hospital efficiency, the HABT presented below-standard medical-hour performance (3.31 in 2018), and lower compared to the HLNV (4.74in2018).Innancialmanagement,forbothmodelsofpublic-privatemanagement,itisagreedthat procurement plans must be carried out in advance, with common problems: ignorance of operational plans, poor epidemiological surveillance, and insufficient strengthening of skills and competencies; likewise, the APP modality spends three times more compared to the traditional modality. Conclusion: A PPP modality health facility, such as the HABT, does not seem to present better results than a traditional format facility such as the HLNV.

Challenges and Opportunities in the Use of High and Maximum Biocontainment Facilities in Developing and Licensing Risk Group 3 and Risk Group 4 Agent Veterinary Vaccines.

New solutions are necessary for the singular global health security threat formed by endemic, epidemic, and emerging/re-emerging zoonoses, coupled with epizootic and enzootic transboundary animal diseases (TADs). This One Health issue is related to the daily interactions between wildlife, domesticated and indigenous livestock, and humans primarily associated with global trade, transboundary co-movement of humans and diverse livestock/livestock products, and agriculture production intensification and penetration into previously uninhabited areas. The World Health Organization defines Risk Group 3 (RG-3) and RG-4 pathogens as mainly viruses but also bacteria that serve as the foundation for approximately 60% of emerging infectious diseases that are zoonoses. The World Organisation for Animal Health defines trade-notifiable TADs, and subsets of these are zoonotic. Livestock vaccination policies mainly focus on TADs that are promulgated by the United Nations Food and Agriculture Organization and government agriculture agencies. The development, licensure, and product manufacturing of next-generation molecular-based RG-3 and RG-4 veterinary vaccines largely ignored by the global animal health biopharmaceutical sector can have an important positive impact on food security and One Health. There have been sharp increases in the global demand for livestock meat and milk products, especially in low- and middle-income countries in Africa and Asia. This relatively recent market driver-coupled with scientific advances in human EID and zoonotic disease vaccine platform technologies and increases in the number of high (US biosafety level 3 agriculture) and maximum (US animal biosafety level 4) biocontainment facilities with supporting workforce capabilities-offers new investment opportunities to the animal health biopharmaceutical sector. Moreover, a growing number of One Health public-private partnerships have moved the net present value calculus in favor of the financial feasibility of RG-3 and RG-4 veterinary vaccine product development and licensure. This article highlights the challenges and opportunities in the use of high and maximum biocontainment facilities in developing and licensing RG-3 and RG-4 veterinary vaccines that are safe and effective against epizootic and enzootic TADs and zoonotic diseases.

Stakeholder engagement and the future of Irish public–private partnerships

Building on recent works that stress the importance of stakeholder engagement in partnerships, we propose a novel benchmarking framework for the evaluation of public–private partnerships. This framework describes mutuality and the preservation of organisational identity as the ideal characteristics of partnerships because they, in turn, encourage stakeholder support for public–private partnerships. Applying this framework to infrastructure public–private partnerships in Ireland, we note that mutual accountability has been weakened following the financial crisis. Meanwhile, consultation with clients such as key public–private partnership stakeholders, which would help articulate organisational identities, remains patchy across the education, justice and health public–private partnership that we investigate. Nonetheless, there are sectoral differences. In education, consultation centres on school principals while ignoring teaching staff and trade unions. In justice, attention is focused primarily on judges. Similarly, in health sector public–private partnerships, there is a strong focus on clinicians. Overall, private sector-driven consultation efforts are primarily pragmatic, with a focus on preventing delays and the dissatisfaction of key clients who could prevent future projects from materialising. We suggest that the combination of this calculated approach to consultation, together with the delegation of public–private partnership contracting to an arm’s-length government agency, is likely to promote a similar depoliticisation of Irish public–private partnerships as has been observed in other countries. We argue that the potentially harmful stakeholder disengagement that this might encourage can be addressed through a concerted set of measures focusing on improved transparency of decision-making, as well as frameworks that mandate client and public consultation. Points for practitioners Research has highlighted the importance of mutual accountability and the preservation of organisational identity in ensuring that public–private partnerships attract public participation and receive public approval. We investigate public–private partnerships in education, justice and health in Ireland, a country that is widely considered an exemplary public–private partnership practitioner. We observe that consultation by private sector public–private partnership participants with client organisations in these sectors is largely motivated by a desire to prevent hold-ups and secure future business rather than seeking to engage with a broad range of users and stakeholders. Together with the existing lack of evidence of benefits from public–private partnerships, this situation is likely to lead to dissatisfaction with the policy. Indeed, political parties critical of public–private partnerships have been able to significantly increase their share of the vote in a recent national election. Our conclusion is that such dissatisfaction is avoidable if the Irish government improves transparency around public–private partnership decision-making while strengthening requirements for public and client consultation.

What does COVID-19 tell us about the Peruvian health system?

ABSTRACT Peru seemed well placed to respond to the COVID-19 pandemic as a country that had achieved sustained economic growth and moved towards achieving universal health coverage. However, Peru has one of the highest rates of transmission and mortality worldwide. This article analyses what the pandemic has unveiled with regards to the health system, arguing that a focus on meeting global development targets, including by promoting public-private partnerships in health, has distracted attention from the underlying structural causes of inequalities and enabled the continuation of a highly fragmented system, with access determined by income, gender, ethnicity and geography.

Power in Global Nutrition Governance

Abstract Global public-private partnerships for health and nutrition have proliferated since the 1990s—a trend raising important questions about authority and legitimacy in global governance. Yet within the fields of international relations and public health, there has been only limited empirical research into the global politics and power dynamics behind such partnerships. This article explores how and why the Scaling Up Nutrition partnership was established. Drawing on interviews, observations, and document analysis, it demonstrates how public and private actors exercise combinations of instrumental, structural, and discursive power to normalize and institutionalize their interests and values at the global level. The study highlights as such the complexities behind the increased privatization of global nutrition governance and the importance of power analysis to uncover the normative contestations and asymmetries of power behind global partnership creation.

Artificial Pancreas Systems for People With Type 2 Diabetes: Conception and Design of the European CLOSE Project.

In the last 10 years tremendous progress has been made in the development of artificial pancreas (AP) systems for people with type 1 diabetes (T1D). The pan-European consortium CLOSE (Automated Glucose Control at Home for People with Chronic Disease) is aiming to develop integrated AP solutions (APplus) tailored to the needs of people with type 2 diabetes (T2D). APplus comprises a product and service package complementing the AP system by obligatory training as well as home visits and telemedical consultations on demand. Outcome predictors and performance indicators shall help to identify people who could benefit most from AP usage and facilitate the measurement of AP impact in diabetes care. In a first step CLOSE will establish a scalable APplus model case working at the interface between patients, homecare service providers, and payers in France. CLOSE will then scale up APplus by pursuing geographic distribution, targeting additional audiences, and enhancing AP functionalities and interconnectedness. By being part of the European Institute of Innovation and Technology (EIT) Health public-private partnership, CLOSE is committed to the EIT “knowledge triangle” pursuing the integrated advancement of technology, education, and business creation. Putting stakeholders, education, and impact into the center of APplus advancement is considered key for achieving wide AP use in T2D care.

Civil society participation in global public private partnerships for health.

The growth of global public-private partnerships for health has opened up new spaces for civil society participation in global health governance. Such participation is often justified by the claim that civil society organizations, because of their independence and links to communities, can help address democratic deficits in global-level decision-making processes. This article examines the notion of ‘civil society engagement’ within major public–private partnerships for health, where civil society is often said to play a particularly important role in mediating between public and private spheres. How do major global health partnerships actually define ‘civil society’, who represents civil society within their global-level decision-making bodies, and what formal power do civil society representatives hold relative to other public and private-sector partners? Based on a structured analysis of publicly available documents of 18 of the largest global public–private partnerships for health, we show that many of them make laudatory claims about the value of their ‘civil society engagement’. Most use the term ‘civil society’ to refer to non-governmental organizations and communities affected by particular health issues, and state that they expect these actors to represent the needs and interests of specific populations in global-level decisions about strategies, funding models and policies. Yet, such civil society actors have a relatively low level of representation within the partnerships’ boards and steering committees, especially compared with private-sector actors (10.3 vs 23.7%). Moreover, there is little evidence of civil society representatives’ direct and substantial influence within the partnerships’ global-level governing bodies, where many decisions affecting country-level programmes are made. Rather, their main role within these partnerships seems to be to implement projects and advocate and raise funds, despite common discourses that emphasise civil society's watchdog function and transformative power. The findings suggest the need for in-depth research into the formal and informal power of civil society within global health governance processes.

Public-private partnerships in practice: collaborating to improve health finance policy in Ghana and Kenya.

Social health insurance (SHI), one mechanism for achieving universal health coverage, has become increasingly important in low- and middle-income countries (LMICs) as they work to achieve this goal. Although small private providers supply a significant proportion of healthcare in LMICs, integrating these providers into SHI systems is often challenging. Public-private partnerships in health are one way to address these challenges, but we know little about how these collaborations work, how effectively, and why. Drawing on semi-structured interviews conducted with National Health Insurance (NHI) officials in Kenya and Ghana, as well as with staff from several international NGOs (INGOs) representing social franchise networks that are partnering to increase private provider accreditation into the NHIs, this article examines one example of public-private collaboration in practice. We found that interviewees initially had incomplete knowledge about the potential for cross-sector synergy, but both sides were motivated to work together around shared goals and the potential for mutual benefit. The public-private relationship then evolved over time through regular face-to-face interactions, reciprocal feedback, and iterative workplan development. This process led to a collegial relationship that also has given small private providers more voice in the health system. In order to sustain this relationship, we recommend that both public and private sector representatives develop formalized protocols for working together, as well as less formal open channels for communication. Models for aggregating small private providers and delivering them to government programmes as a package have potential to facilitate public-private partnerships as well, but there is little evidence on how these models work in LMICs thus far.

Mission and State Health Institutions: “Invisible” Public-Private Partnerships in Zimbabwe, 1980–1999

This article argues that Zimbabwe’s independence in 1980 marked not the end of the missionary era, but its high point. Government’s poor rural health infrastructure forced it to partner missionary health institutions in order to run preventive health programmes and improve access to health services for the majority of the population. Mission health institutions formed the mainstay of rural African health care needs in the colonial period and continued to do so in the post-colonial period; with 97 clinics and 70 hospitals, and 13 of the country’s 42 designated district hospitals compared to 1 032—largely small and urban based—government, council and private health facilities. Mission health institutions were regulated by the Ministry of Health and were partly funded by the government. However, the significance of the mission health endeavour was overshadowed by an overarching government development agenda and narrative. This study establishes the nature and forms of public-private health partnerships in the development of Zimbabwe’s public health system and highlights the importance of the church’s healing mandate. It also refracts on church-state relations and the broader development and policy issues during the 1980s and 1990s.&#x0D;

Exploring public private partnerships in health and education: a critique

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Gender blind? An analysis of global public-private partnerships for health

BackgroundThe Global Public Private Partnerships for Health (GPPPH) constitute an increasingly central part of the global health architecture and carry both financial and normative power. Gender is an important determinant of health status, influencing differences in exposure to health determinants, health behaviours, and the response of the health system.We identified 18 GPPPH - defined as global institutions with a formal governance mechanism which includes both public and private for-profit sector actors – and conducted a gender analysis of each.ResultsGender was poorly mainstreamed through the institutional functioning of the partnerships. Half of these partnerships had no mention of gender in their overall institutional strategy and only three partnerships had a specific gender strategy. Fifteen governing bodies had more men than women – up to a ratio of 5:1. Very few partnerships reported sex-disaggregated data in their annual reports or coverage/impact results. The majority of partnerships focused their work on maternal and child health and infectious and communicable diseases – none addressed non-communicable diseases (NCDs) directly, despite the strong role that gender plays in determining risk for the major NCD burdens.ConclusionsWe propose two areas of action in response to these findings. First, GPPPH need to become serious in how they “do” gender; it needs to be mainstreamed through the regular activities, deliverables and systems of accountability. Second, the entire global health community needs to pay greater attention to tackling the major burden of NCDs, including addressing the gendered nature of risk. Given the inherent conflicts of interest in tackling the determinants of many NCDs, it is debatable whether the emergent GPPPH model will be an appropriate one for addressing NCDs.

"Lives in the balance": The politics of integration in the Partnership for Maternal, Newborn and Child Health.

A decade ago, the Partnership for Maternal, Newborn and Child Health (PMNCH) was established to combat the growing fragmentation of global health action into uncoordinated, issue-specific efforts. Inspired by dominant global public-private partnerships for health, the PMNCH brought together previously competing advocacy coalitions for safe motherhood and child survival and attracted support from major donors, foundations and professional bodies. Today, its founders highlight its achievements in generating priority for ‘MNCH’, encouraging integrated health systems thinking and demonstrating the value of collaboration in global health endeavours. Against this dominant discourse on the success of the PMNCH, this article shows that rhetoric in support of partnership and integration often masks continued structural drivers and political dynamics that bias the global health field towards vertical goals. Drawing on ethnographic research, this article examines the Safe Motherhood Initiative’s evolution into the PMNCH as a response to the competitive forces shaping the current global health field. Despite many successes, the PMNCH has struggled to resolve historically entrenched programmatic and ideological divisions between the maternal and child health advocacy coalitions. For the Safe Motherhood Initiative, the cost of operating within an extremely competitive policy arena has involved a partial renouncement of ambitions to broader social transformations in favour of narrower, but feasible and ‘sellable’ interventions. A widespread perception that maternal health remains subordinated to child health even within the Partnership has elicited self-protective responses from the safe motherhood contingent. Ironically, however, such responses may accentuate the kind of fragmentation to global health governance, financing and policy solutions that the Partnership was intended to challenge. The article contributes to the emerging critical ethnographic literature on global health initiatives by highlighting how integration may only be possible with a more radical conceptualization of global health governance.

Public-Private Partnerships In Health

Extract: The current importance of public debt requires governments to increasingly shift towards Public-Private Partnerships (PPPs). They are long-term contracts of private financing method providing or contributing to public service. The payment is made by the public partner and/or users of the service. The World Health Organization (WHO) defines this type of partnership as ‘‘a means to bring together a set of actors for the common goal of improving the health of populations based on mutually agreed roles and principles.’’ Historically, the principle of PPP was established by the Private Finance Initiative (PFI), launched by the conservative government of John Major in 1992. It was from this moment that this model quickly spread to the rest of the world. In the mid-90s and from Australia, PPP agreement began to become part of the language of governments. In 1997, Labour with Tony Blair leading, strongly developed this management method, first and particularly in hospitals and then, in the entire public sector and spreading to the Royal Navy. Today, 10-15% of British public investments are made using PFI method.

Investing in Onchocerciasis Control: Financial Management of the African Programme for Onchocerciasis Control (APOC)

The African Programme for Onchocerciasis Control (APOC) has been described as one of the most successful public-private partnerships for health in Africa [1]. The Programme helps the governments of 20 onchocerciasis-endemic countries to develop sustainable delivery of ivermectin treatment in order to control and eliminate river blindness [2]. APOC is one of a very few programs that the WHO implements directly, in this case through the Regional Office for Africa (AFRO) and the APOC Secretariat established in Ouagadougou, Burkina Faso. As the Executing Agency of APOC, WHO is responsible for the development of procedures for implementing community-directed treatment with ivermectin (CDTi), approving funding to countries, maintaining surveillance, and ensuring monitoring and evaluation [3]. The Executing Agency supports governments directly in this role, aided by a group of 15 Non-Governmental Development Organizations (NGDOs), operating nationally, regionally, and globally [4]. The 15 NGDOs include Charitable Society for Social Welfare, Christoffel-Blindenmission (CBM), Helen Keller International (HKI), Light the World, Mectizan Donation Program (MDP), Mission to Save the Helpless (MITOSATH), Organisation pour la Prevention de la Cecite (OPC), Sightsavers International, United Front Against Riverblindness (UFAR), Interchurch Medical Assistance (IMA) World Health, Lions Clubs International Foundation, Malaria Consortium, Schistosomiasis Control Initiative, The Carter Center, and The United States Fund for UNICEF. The funding for national onchocerciasis control comes from the countries and civil society, with additional funding from APOC through contributions from more than 30 development partners to a Trust Fund that the World Bank manages in its role as Fiscal Agent. Scheduled to close in 2015, the main governing body of APOC decided to set up a new programme for a ten-year period from 2016, actively seeking to eliminate river blindness from most of Africa by 2025 and, by strengthening the same health system that successfully delivered treatment for river blindness, seeking to also eliminate lymphatic filariasis and co-implement treatments for the five other major preventable neglected tropical diseases (NTDs) that can be addressed through mass drug administration. Plans are underway to transform APOC beyond 2015 and transition from a single-disease entity to an expanded regional NTD initiative [5]. This article is one of a series developed by the partnership of agencies, institutions, and individuals that make up APOC. This article is written from the perspective of the Fiscal Agent (the APOC Team at the World Bank) and should be read in conjunction with the corresponding articles in this series that examine the depth and diversity of the river blindness partnership, which includes the Executing Agency (World Health Organization) [3], civil society [4], and the Mectizan Donation Program [6].

A concept in flux: questioning accountability in the context of global health cooperation.

BackgroundAccountability in global health is a commonly invoked though less commonly questioned concept. Critically reflecting on the concept and how it is put into practice, this paper focuses on the who, what, how, and where of accountability, mapping its defining features and considering them with respect to real-world circumstances. Changing dynamics in global health cooperation - such as the emergence of new health public-private partnerships and the formal inclusion of non-state actors in policy making processes - provides the backdrop to this discussion.DiscussionAccountability is frequently reduced to one set of actors holding another to account. Changes in the global health landscape and in relations between actors have however made the practice of accountability more complex and contested. Currently undergoing a reframing process, participation and transparency have become core elements of a new accountability agenda alongside evaluation and redress or enforcement mechanisms. However, while accountability is about holding actors responsible for their actions, the mechanisms through which this might be done vary substantially and are far from politically neutral.Accountability in global health cooperation involves multipolar relationships between a large number of stakeholders with varying degrees of power and influence, where not all interests are realised in that relationship. Moreover, accountability differs across finance, programme and governance subfields, where each has its own set of policy processes, institutional structures, accountability relations and power asymmetries to contend with. With reference to the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria, this paper contributes to discussions on accountability by mapping out key elements of the concept and how it is put into practice, where different types of accountability battle for recognition and legitimacy.SummaryIn mapping some defining features, accountability in global health cooperation is shown to be a complex problem not necessarily reducible to one set of actors holding another to account. Clear tensions are observed between multi-stakeholder participatory models and more traditional vertical models that prioritise accountability upwards to donors, both of which are embodied in initiatives like the Global Fund. For multi-constituency organisations, this poses challenges not only for future financing but also for future legitimacy.

Global Public-Private Health Partnerships: lessons learned from ten years of experience and evaluation

Global Health Partnerships (GHPs) have contributed significantly to improved global health outcomes as well as the manner in which global health is governed. Yet in a context of an increasingly complex global health landscape, resource scarcity and a shift from disease-specific to systems strengthening approaches, it is important to continually enhance and apply our understanding of how to improve GHP performance. The authors reviewed and synthesised findings from eight independent evaluations of GHPs as well as research projects conducted by the authors over the past several years, the most recent of which involved semi-structured discussions with 20 ‘partnership pioneers’. This paper presents the major drivers of the GHP trend, briefly reviews the significant contributions of GHPs to global health and sets out common findings from evaluations of these global health governance instruments. The paper answers the question of how to improve GHP performance with reference to a series of lessons emerging from the past ten years of experience. These lessons cover the following areas:•Value-added and niche orientation•Adequate resourcing of secretariats•Management practices•Governance practices•Ensuring divergent interests are met•Systems strengthening•Continuous self-improvement.These and other critical reflections inform the ‘what’s next’ agenda for GHP development.

Seven habits of highly effective global public–private health partnerships: Practice and potential

Global public–private health partnerships (GHPs) have become an established mechanism of global health governance. Sufficient evaluations have now been conducted to justify an assessment of their strengths and weaknesses. This paper outlines seven contributions made by GHPs to tackling diseases of poverty. It then identifies seven habits many GHPs practice that result in sub-optimal performance and negative externalities. These are skewing national priorities by imposing external ones; depriving specific stakeholders a voice in decision-making; inadequate governance practices; misguided assumptions of the efficiency of the public and private sectors; insufficient resources to implement partnership activities and pay for alliance costs; wasting resources through inadequate use of recipient country systems and poor harmonisation; and inappropriate incentives for staff engaging in partnerships. The analysis highlights areas where reforms are desirable and concludes by presenting seven actions that would assist GHPs to adopt better habits which, it is hoped, would make them highly effective and bring about better health in the developing world.