Secretary Clinton has said, "The problems we face today will not be solved by governments alone. It will be in partnerships - partnerships with philanthropy, with global business, partnerships with civil society." As PEPFAR shifts to promotion of country-led sustainable responses, it is essential to employ all possible mechanisms to build systems and expand capacity.

Public-Private Partnerships

Public-private partnerships (PPPs) are a tool that can enhance PEPFAR and country government approaches to HIV/AIDS and strengthening of overall health systems. PEPFAR has worked with public-private engagement mechanisms throughout the government, including the Department of State's Global Partnerships Initiative. Over the past three years, PEPFAR has made significant strides in brokering PPPs and establishing relationships with key private sector entities.

Private sector partners have skills that complement PEPFAR's technical focus, including marketing and distribution networks. Many of PEPFAR's private sector partners have specific technical expertise in areas such as laboratory capacity and information technology. PEPFAR has worked to link their capabilities with areas of program emphasis to leverage not just dollars, but results that can be sustained in the long term.

Over the next phase of PEPFAR, the program is developing partnerships that will deliver impact with low transaction costs. There will be an emphasis on partnerships supporting prevention, broad health systems strengthening, and human resources for health. PEPFAR's PPP projects will explicitly integrate gender strategies as a cross-cutting element wherever feasible. The following are ways that PPPs can support the vision for the next phase of PEPFAR:

• Identifying and promoting integration of the private sector in service delivery. According to a 2007 study conducted for the World Bank/IFC by McKinsey, around 60% of sub-Saharan Africa's total health expenditures were financed by private parties; about 65% of that was directed to for-profit providers.¹¹ This spending is not based on wealth. According to a compilation of Demographic and Health Surveys (DHS) from 10 sub-Saharan African countries, 44% of those in the poorest quintile brought their sick children to private, for-profit, providers.¹² PEPFAR must work with partner governments to help them identify and understand the role that private and non-profit providers currently play in the response to the disease. Doing so allows governments to coordinate with these private partners as part of a comprehensive national health system.
  
• Facilitating provision of technical assistance in areas of core competencies. The private sector can work directly with government officials and healthcare workers to build their capacity and strengthen national health systems. As PEPFAR focuses on increasing capacity-building and technical assistance to governments, it can help to facilitate relationships between partner countries and businesses supporting development of core competencies.
  
• Supporting North-South and South-South mentoring programs. Part of PEPFAR's PPP mandate is to engage professional organizations and companies, diaspora groups, and even individuals involved in PEPFAR programs. Leading HIV/AIDS experts, clinicians, nurses, and practitioners in the United States can play an important collaborative role with their counterparts in PEPFAR countries. Over the next phase of PEPFAR, the program is expanding collaborative and mentoring relationships with partner governments.
  
• Expanding and integrating workplace programs. In many countries, businesses were and are on the leading edge of the response to HIV/AIDS, given the threat that the epidemic poses to the stability of the local economy. However, the development of workplace programs has not always been linked to a national HIV/ AIDS prevention response. Private companies can play a leading role in the sustained response to the disease through the workplace, but a new, up-to-date strategy for engagement needs to be developed. PEPFAR can help governments ascertain the landscape of workplace programs and attain efficiencies by ensuring coordination of workplace efforts with larger public programming.
  
• Integrating gender strategies. PPPs play an important role in PEPFAR's gender programming strategy. PEPFAR engages with private companies to address structural issues that impact women and men's risk for HIV infection and access to quality care and treatment. The private sector can play a strong role in mobilizing investment capital to support women's access to income and productive resources. With increased emphasis from both PEPFAR and external actors on gender-based violence, PEPFAR is working to develop partnerships around this specific issue. PEPFAR can also do more to engage women as both providers and recipients of private sector health services. These private services must be strategically linked to reproductive health, family planning, and maternal care, and serve as a conduit to get families into HIV and other health services.