The pharmaceutical sector is like any other business in its desire to supply goods and services to the most lucrative markets. Yet in a world of increasing wealth inequality, where the poorest populations are in most need of medicines for basic diseases, there is a gap to be bridged between business practice and human need.

The money and resources channelled by the pharmaceutical sector into the diseases that most afflict the poor, such as malaria and tuberculosis, pale in comparison to the huge sums poured into finding cures for diseases that predominate in wealthy nations, such as heart disease and cancer. Are the majority of those living in poverty in the developing world being neglected by the free market system? Health and development organizations argue strongly that this neglection is not only a moral failure but, as the impact of HIV/AIDS in Africa has so tragically shown, it has far reaching practical and economic implications for societies whose populations are crippled by diseases that could be cured quite simply.

Health problems of developing countries are no longer being financed purely through public funding. New partnerships are emerging between the public and private sectors. One of these new forms of health development and governance, Public Private Partnerships (PPPs), is discussed in this issue of the Monitor. A central issue in analysing these new institutional structures is how effective they are in addressing the health needs of the poor, and what their impact is on public and inter-governmental health work at field level.

There are a growing number of PPPs that focus on medical R&D and the delivery of drugs and vaccines, as the articles of Lehmann and Levings & Kahn show. Looking more closely, however, the term 'partnership' might be a misnomer as Walt & Lush explain. Areas of concern are the structural inequality between partners, and the burdens placed on the administrative and health care facilities of poor countries responsible for implementing the drug programmes and health regimes developed by PPPs. The articles show that the political and scientific arena is not as simple as the term 'public-private' suggests. PPPs are not just cooperations between the R&D facilities of public institutes and private companies. 'Private' also includes private foundations whose philanthropic agendas have been determined by the ideologies of their founders and trustees, and whose activities are fuelled by corporate wealth. In practice the public sphere is equally differentiated and includes not only publicly funded research groups but also inter-governmental organizations like the World Health Organization and non-governmental organizations. Whilst these organizations might certainly do good work they are not always publicly accountable.

PPPs are using a new approach to get the most appropriate drugs and vaccines to those who need them. They have also taken up the challenge of those neglected diseases that are by-passed by the conventional market. Most PPPs try to bridge this gap by creating a workable market either by reducing the R&D costs for the producer through grants, by guaranteeing revenues through higher prices on other markets or through allocating money to purchase drugs.

This concept might succeed and deliver the drugs, but at the same time it could lead to a situation in which parts of the world rely on research systems that are largely privately organized and financed. Therefore, a critical analysis is necessary of the power relations within the PPPs and their impacts on those inter-governmental organizations responsible for public health.

The problem of access by the needy to drugs developed and patented in the private sector has become a prominent world issue. Governments like that of South Africa risk being restricted from producing affordable generic drugs by new inter-governmental patent restrictions, particularly the TRIPS agreement. However in April 2001, pharmaceutical companies, mindful of their public image, declined from pushing their case through the South African courts. In this case the victory was for the South African people in need of health care, but outcomes might not always be so positive, especially if new global rules are adhered to.

The global community needs to look more closely at drug development and distribution. Should global governance on such important issues as human health be guided by cycles of business opportunism and public outcry? What happens if in the case of the most needy there is no outcry, or if it is not loud enough for business to change its line? Such an inconsistent approach to global governance should be of major concern to policy makers.