Another crucial stakeholder in PPPs is the public-that is, the general population. Compliance-patient adherence to pharmaceutical treatments and lifestyle interventions-is notoriously difficult. According to the National Institutes of Health, upwards of 40% of patients do not comply precisely with doctor recommendations,44 and NCD interventions-which generally rely on sweeping changes to diet and exercise habits-are much more difficult to comply with than a prescription drug regimen. Ultimately, the success of a healthcare PPP is highly contingent on partners' ability to engage the public as a partner. Nowhere has the importance of effective public engagement been more apparent than in the 2020 outbreak of Covid-19. Though the situation is-as of this writing-still developing, the fight to implement "social distancing" measures among citizens has demonstrated the importance of effective public engagement. A similar dynamic-though not quite as immediate-exists in the NCD space, as we will explore over the next few pages.
Another potent example of engaging the public as a partner-albeit not in the healthcare space-comes again in the form of New York City's parks.
| CASE STUDY New York City Parks and Partnerships Let's revisit the New York City parks system once more. We have already discussed how the public sector was able to harness the untapped value of Central Park, Bryant Park, and the High Line by developing a network of private donors and creating a Business Improvement District. But these cases also provide illuminating examples of engaging the public as a partner, because much of the upkeep and maintenance of New York's world-famous parks is done on a volunteer basis. Volunteers in park conservancies and related organizations perform most of the flower-planting, gardening, and clean-up in New York City. By 2003, The Partnership for Parks, the organization that coordinates this volunteer effort, had somewhere near 70,000 volunteers in its database. For a public service, engaging neighbors as volunteers offers numerous benefits. First, and most obviously, volunteers are free. A volunteer base of 70,000 people is able to seriously reduce labor costs for park maintenance. In fact, in 2002, volunteers logged over one million hours in support of the parks-estimates indicate that the parks department saved $40 million on civil service staffers. But, volunteers offered another, less obvious benefit: buy-in. Because citizens were putting their own effort into the parks, they were less inclined to litter or deface them. Even those who did not volunteer directly were able to appreciate the efforts of their neighbors: "By enlarging the circle of 'ownership,' moreover, partnerships were seen to alter for the better the ways New Yorkers thought about and behaved toward the parks... A receptionist at a Wall Street firm might hesitate to let her dog run unleashed in Bryant Park if her company's CEO was on the board of the Restoration Corporation. An Upper East Side teenager whose father planted flowers with the Conservancy every spring might steer his skateboard more carefully through Central Park, and his Queens counterpart whose mother stood watch four hours a week at the neighborhood playground might resist the temptation to visit that playground late at night to adorn it with graffiti. It was hard to calibrate the impact of such effects...but parks officials and their private partners were convinced these kinds of shifts in attitude and perception were pivotal to the improvement of New York's park system."45 |
By engaging the public successfully, New York City was able to not only minimize labor costs with volunteers, but also reduce the overall burden of maintenance by harnessing the enthusiasm that comes with strong community buy-in.46
Healthcare PPPs should strive to do the same. For one, an engaged public-one that takes positive steps to improve NCD outcomes-is one that complies with regular screening recommendations and adheres to treatment regimens prescribed by doctors. And by engaging proactively in their own health, eating nutritiously, exercising regularly, and abstaining from destructive behaviors like smoking, an engaged public will incur fewer "maintenance costs" over time, to borrow an analogy from New York's parks.
In other words, each human body within a given country should be looked upon as an asset. Certainly, when a person is sick, that asset can become a liability-a costly drain on society and a "missing worker" from the country's labor force. But, if those bodies can be made healthy, they can become powerful assets-spurring growth, driving innovation, and boosting productivity.
By engaging the public as a partner, Singapore's Health Promotion Board managed to "narrow the funnel" for healthcare services, while turning the liabilities of some of its sick citizens into assets.
| EXAMPLE Singapore's Health Promotion Board We have discussed how the HPB worked to reduce demand for NCD treatments by engaging with younger populations to "narrow the funnel" before the populations aged. Yoong Kang Zee, the CEO of HPB, who assumed the role in 2013, knew that there had to be a way to engage the public in funnel-narrowing initiatives. The Health Promotion Board attempted to engage the public through a series of initiatives, including the "Healthier Choice" symbol, which we discussed earlier, but also by promoting exercise among the general public, encouraging workplace fitness programs, and even establishing new fitness centers in public places like parks and shopping malls. HPB also engaged in a massive public education program, providing the public with credible information on diet, exercise and other health-related topics, and cultivated an extensive system of health "ambassadors," some 4,500 volunteers tasked with promoting healthy living in their communities. By engaging the public effectively in their own wellbeing, Singapore's HPB was able to effectively reduce long-term demand for NCD-related care. These initiatives may not have had an immediate payoff, but will make caseloads more manageable in the future by curbing NCD incidence. |
Of course, NCD reduction in narrowing the funnel is not only a matter of reaching large numbers of citizens with interventions, but also a matter of reaching the right citizens. By targeting efforts most heavily at those citizens who are most at risk for a given NCD, governments can increase their return on investment. This is an area where private-sector intervention has been consistently under-utilized.
With each passing year, big data becomes a more omnipresent fixture in our lives, influencing the kinds of advertisements we're exposed to, what news articles we see, and even tracking our personal calendars and whereabouts. The privacy concerns presented by this growing accumulation of data by large technology companies have been heavily scrutinized, and rightly so. But the potential for big data to profoundly impact healthcare outcomes has been, so far, under-leveraged. Wearables, mobile apps, and smartphones can all generate huge amounts of medical data, which could be used to identify risk factors, identify at-risk citizens, and manage ongoing disease. Ballantyne and Stewart identify three main ways that medical data can be used across the public and private sectors, including "Private sector organisations apply[ing] to use public sector data for research; electronic health records include[ing] data generated in the private sector (apps, private hospitals, private specialist providers) and data produced by public health agencies; and public and private sector agencies form[ing] partnerships to pool resources and/or expertise to provide clinical care, or support research, innovation and product development."47
The presence of big data in healthcare PPPs raises privacy concerns as well, particularly where the commercialization of medical data is concerned. As Ballantyne and Stewart write, "Empirical research consistently suggests public discomfort with the use of health data for commercial gain, or with commercial (for-profit) companies accessing their health data."
Though the ethics of privacy are well beyond the scope of the Healthcare PPP Guide, the potential political hazards of a perceived government or private-sector overreach are apparent. A thorough stakeholder analysis would consider existing cultural norms, national and provincial privacy laws, and the need for a strong and clear communication strategy, if data was to be included in healthcare. Furthermore, ambitious convenings-bringing together the public, private, healthcare, and technology sectors-could help to bridge the significant gaps preventing governments from capitalizing fully on the potential benefits of a technologically-driven approach to healthcare.
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44Martin, L., Williams, S., Haskard, K., & DiMatteo, M. "The Challenge of Patient Adherence ," Therapeutics and Clinical Risk Management, 2005, 189-199.
45John D. Donahue, "Parks and Partnership in New York City," Harvard Kennedy School, 2004, Case Number HKS086 (Based on research by Donahue and Center for Business and Government Senior Fellow Alan M. Trager, with assistance from Jordana Rubel.)
46Disclosure: Professor Alan M. Trager served as the Chairman of the Board of the Riverside Park Conservancy
47 https://link.springer.com/article/10.1007/s41649-019-00100-7