Debate sobre o artigo de Costa e Silva et al.

Abstract

The article deals with public-private partnerships, an extremely relevant theme for public health in a time of criticism towards the action of national states, on grounds of purported structural defects or operational inefficiency. For public health, but not only for it, the most visible face of this critical disposition is the dissolution of the multilateral framework's tools for dispute-resolution and formation of consensuses. From my point of view, since this issue lies at the origin of the proliferation of partnerships, perhaps it should occupy greater space in the debate proposed by the authors. Along with the development of bilateral or plurilateral mechanisms, the crisis of multilateralism has been leveraged by the financial strangulation of multilateral agencies, whose budgets are now comprised mainly of donations by private entities and companies. Importantly, in the case of the World Health Organization (WHO), the budget share coming from mandatory contributions by Member States is less than 20%. A recent manifestation of this problem was the nomination of the Saudi Arabian Ambassador to the position of Chair of the United Nations Human Rights Council, when the Saudi political regime is known to be one of the most repressive in the world (see for example http://blog.unwatch. org/index.php/2015/09/20/saudi-arabia-wins-bid-to-behead-of-un-human-rights-council-panel/). I also noted that the article did not comment on the most common current partnership modalities in public health, which do not involve industrial companies, but services companies. In Brazil, for example, outsourcing of outpatient and hospital services to non-profit or for-profit private organizations has been the target of intense debate concerning their results, with well-founded doubts. Would such partnerships be "possible", "possible with caveats", or "impossible"? I think it would be extremely helpful to qualify the risks of some partnerships in force in Brazil, both in healthcare services (for example, the outsourcing of health services in Rio de Janeiro and São Paulo) and in the industrial area (e.g., the industrial development policy led by the Ministry of Health with participation by the National Bank for Economic and Social Development-BNDES). Returning to the categorization of partnerships, perhaps the study's most important contribution would be to explore the gap between "intent and gesture" in public-private partnerships (PPPs). For example, the successful British partnership to reduce salt intake was negotiated between government and some industries that were clearly harmful to public health, such as the processed and frozen foods industries. Therefore, while maintaining an overall classification of partnerships as the article does so well, it might be helpful to take a "case by case" approach, depending on the contract's terms (intent) and especially its execution (gesture). These comments should be seen as potential additions to the article rather than criticisms. The work by the WHO and Sergio Arouca National School of Publ...