Navigating the role of the private sector in health emergencies

It is now a common refrain in contemporary international relations that the modern state is in retreat. Views vary on the extent of that retreat, ranging from marginal to a full rout (Bauman and Bordoni 2014; Schneider and Häge 2008; Strange 1996); and of course, as the academy is prone to do, there are those who problematize such claims to argue the reverse (Grygiel 2016; Helm 2013; Levy 2016). Conceivably the only common ground is that the international system has become far more complex, in large part due to the proliferation of actors. The second feature that may also enjoy some consensus is that the structures, systems, institutions and processes created in the first half of the twentieth century are no longer fit for purpose in the first half of the twenty-first.

One of the core concerns frequently heard alongside ‘the retreat of the state’ apologue has been the rise of the private sector. This has been particularly pronounced within the humanitarian and development communities which, historically, have been characterized by non-government organizations supported in their work through foreign aid budgets and philanthropic donations. Although it has long been accepted that private sector actors can serve a useful function due to their logistical capabilities (which can be co-opted to help humanitarian organizations achieve their objectives, and thus are considered acceptable as they serve a ‘greater good’) (Holguín-Veras et al. 2012; Van Wassenhove 2006), the role of profit-motivated entities beyond this task has remained controversial. Indeed, concerns regarding these organizations’ motivations, lack of transparency, participation, and political and/or administrative accountability persist (Carpenter and Kent 2016; Richey and Ponte 2014); and within some segments of the development community in particular, suspicions run deep that the emergent ‘public-private partnerships’ disregard unequal power relations to the detriment of the most vulnerable elements of society (Miraftab 2004). Although often left unspoken, the fundamental issue underlying this distrust is how organizations, motivated by profit, should be permitted to operate in environments that are punctuated by profound human misery.

On the converse side, a number of industry representatives and companies maintain that such criticisms are outdated and no longer accurately represent the majority of private sector actors that work in the humanitarian space. They point to entities such as the United Nations Global Compact that was established in 2000 to align business interests and behaviour with achieving and supporting broader societal goals, including sustainable development (United Nations 2016); the rise of ‘corporate social responsibility’ as standard business praxis; and a multitude of successful public–private partnerships that have been created in the health and development sectors. More specifically within the humanitarian space, since the 1990s, there has been a discernable rise in the number of ‘business-humanitarian partnerships’ or BHPs, which have gained a level of legitimacy following the production of ethical guidelines, frameworks and principles under which these entities operate (Andonova and Carbonnier 2014; Carbonnier and Lightfoot 2016). When collectively viewed, advocates argue that the ‘private turn’ in contemporary humanitarianism should not to be shunned but embraced on the basis that the business sector can – and importantly already does – contribute to humanitarian endeavours in a meaningful way.

In this special section, we examine the role of the private sector in health-related humanitarian response. The impetutus for these papers arose from two synchronous occurrences, the first of which was a successful application to the United Kingdom’s Economic and Social Research Council (ESRC) to host a series of workshops on the theme of global health security. Seven different institutions collaborated to hold a total of eight workshops that explored topics such as the role of pharmaceuticals in ensuring global health security, the involvement of militaries in health, halting violence against health care workers, and the politics and geographies of non-communicable disease. The workshop that informed the papers for this special section was the only one to be held outside of Europe, but it brought together international and national experts from the scholarly, government, industry and practitioner communities to consider the role and function of private sector actors in health crises.

The second event was the revelation that the world’s largest ever outbreak of Ebola virus disease was underway in West Africa. As the international community struggled to respond in an appropriate and timely manner, tens of thousands of people became infected and over 11,000 people died. Within Australia, a debate emerged over what role – if any – the Australian Government should play in responding to the crisis. While some advocated deploying members of the Australian Defence Force alongside the military forces from the United States, China, Canada, Germany, France and the United Kingdom, others called for the deployment of the country’s civil–military medical assistance teams (AUSMAT) that had been created in the wake of the 2002 terrorist bombings in Bali, Indonesia, that tragically took the lives of 202 people. Eventually, the government settled upon engaging the services of a private sector actor, Aspen Medical, to provide the Australian Government’s response.

By all accounts,¹ this company and its personnel executed their duties professionally and in an appropriate manner. But it nevertheless raised the question as to what was the appropriate role and function of private service providers in future health-related humanitarian crises. Where are the boundaries of private sector engagement in humanitarian assistance? Are there specific ethical considerations when the crisis or disaster is precipitated by a disease outbreak? To what extent should this new trend be embraced or resisted by the humanitarian and business communities? To consider these questions and others, a small group of international and national policy-makers, scholars and industry representatives met in Sydney, Australia, in November 2015. The two papers and commentary in this special section arose from those deliberations.

The commentary written by Irene Lai and Amy Simpson offers an insight into how one company, International SOS, sought to support a number of their clients respond to the Ebola outbreak in West Africa while also contributing to the broader international response. The article reveals how this company sought to help contain the outbreak, not only by creating information portals that were made freely accessible, but also by creating information products for distribution and permitting staff with skills in demand to take leave-without-pay so that they could respond directly. It also highlights one of the challenges for coordination that remains, namely, the lack of any established mechanism for private sector contributions.

In his paper, Jeremy Youde provides a very timely reminder of the historical role that private sector and philanthropic organizations have played in global health. Youde examines the activities of key actors such as the Rockefeller Foundation and the Bill and Melinda Gates Foundation, surveying how these organizations have contributed to and shaped the global health agenda over the years, as well as some of the key criticisms that have emerged. He goes on to note three central observations: that the influence these actors enjoy is often as a consequence of state retreat; that they hold particular world views that inform their activities that we need to be cognizant of; and that despite centuries of involvement there still remain questions over the legitimacy of these organizations principally because we – as the international community – still lack sufficient mechanisms to assess their worth and behaviour.

Carmen Huckel Schneider and Joel Negin’s essay examines the ethical issues associated with governments contracting private service providers to undertake humanitarian work. They seek to put forward a framework to inform academic debate and practical decision-making based on five key questions that decision-makers should consider. In this respect, the paper not only reviews some of the critical questions and issues confronting the involvement of for-profit actors in a field that has been traditionally home to not-for-profit entities and faith-based organizations, but also offer some practical steps to bridge some of the divides that remain.

The contribution to the literature these three pieces make is significant, principally because the role of private sector actors in health-related humanitarian crises remains an underexplored area of praxis. What is certain is that these organizations are here to stay. Moreover, events like the 2014 Ebola outbreak reveal that for-profit actors can and do make an important contribution (Tambo 2014). Accordingly, as expectations regarding the utility and role that private sector actors can play in the humanitarian space continues to grow, it behoves all parties – government, humanitarian and business communities alike – to weigh carefully the shape, extent and nature of for-profit contributions, and ensure that valuable lessons are learned and incorporated. In this respect, in publishing this special section Medicine, Conflict and Survival continues to remain at the forefront of policy-relevant research in the humanitarian medical response field, and I am certain that as devoted readers you will find them of particular interest.

Notes on contributor

Adam Kamradt-Scott is an associate professor at the Centre for International Security Studies, which is located within the Department of Government and International Relations at the University of Sydney. His research examines how governments and multilateral organizations cooperate and interact when adverse health events such as disease outbreaks, epidemics and pandemics occur, as well as how they respond to emerging health and security challenges. His most recent research examines civil–military cooperation in health and humanitarian crises, and the correlations between gender, sexuality, health and security. Adam has published three books and over 25 journal articles and book chapters. His most recent book, entitled Managing Global Health Security, was awarded the 2016 International Studies Association Global Health Book Prize.

Adam Kamradt-Scott
Centre for International Security Studies, University of Sydney, Sydney, Australia
[email protected]

Notes

1. These observations are based on semi-structured interviews undertaken in Liberia and Sierra Leone in March and April 2015, during the Ebola outbreak.