We wish to begin by thanking the discussants of our article for enlightening the debate on Public-Private Partnerships (PPP) in the field of health. The nature of the article sparks debate on the good faith of certain PPPs, especially when they involve large corporations, like the tobacco industry, and the public sector. Although the tobacco industry has a well-established legal framework, it amounts to a company selling a drug that kills one out of two of its consumers. Since 1998, several authors ¹1. Kickbusch I, Quick JD. Partnerships for health in the 21st century. World Health Stat Q 1998; 51: 68-74. have emphasized that the goal of PPPs should be “to improve the health of populations”, which obviously does not apply to the tobacco industry, but which may apply to some companies focused on the development of well-being, as cited in the article ²2. World Health Organization. Executive Board, 107. "Guidelines to Working with the Private Sector to Achieve Health Outcomes: Report by the Secretariat." World Health Organization, 2001. http://apps.who.int/iris/handle/10665/78660 (acessado em 05/Jul/2017).
http://apps.who.int/iris/handle/10665/78... . In the case of the tobacco industry, the World Health Organization Framework Convention on Tobacco Control (WHO-FCTC), Article 5.3, provides that the interests of public health should be protected from the tactics adopted by this industry, and the article’s discussants were incisive about the extent to which PPPs entail the notion of risk and ideologies, pertaining to our status as a consumer society.

Galvão’s comments call attention to the risks posed to the public good by PPPs. He cites the example of tobacco farmers’ health and the factors involved in agricultural and industrial tobacco production, as well as the need to assess the entire production cycle to determine the risk. Tobacco farmers are constantly exposed to harsh sun, highly toxic pesticides, and the nicotine in tobacco leaves. However, this situation could improve dramatically if Articles 17 and 18 of WHO-FCTC were complied with and farmers could access credit lines to reduce the area of their tobacco crop, transforming their properties into places where healthy, pesticide-free foods is produced.

The discussant Johns raised an extremely relevant issue, namely the increase in obesity due to the consumption of ultra-processed foods, and suggests adding the element of “risk of association” to the analysis for categorization of PPPs. It is inconceivable for a public health institution to partner with the fast food industry to maintain its functioning, as occurs in some Brazilian institutions. On then other hand, it is equally unthinkable for public health policies not to prioritize health institutions in the prevention and treatment of noncommunicable diseases, with priority for the maintenance and proper functioning of such services.

Rodrigues questions the nature of PPPs and asks whether what prevails is collaboration or competition. Likewise, he also questions the feasibility of partnerships with corporations, considering their commercial interests and principles, such as the corporate “bottom line principle”. In fact, it is extremely important for these two aspects to be scrupulously analyzed when considering a possible PPP. The example of a PPP with the tobacco industry adequately illustrates an unsuccessful partnership, where if the factors involved in the nature of the partnership and the industry’s commercial interests are not analyzed, competition and the private party’s economic interests prevail. Thus, one way to avoid a PPP with such characteristics is to follow the guidelines developed by the United Nations for working with the private sector in pursuit of health results ²2. World Health Organization. Executive Board, 107. "Guidelines to Working with the Private Sector to Achieve Health Outcomes: Report by the Secretariat." World Health Organization, 2001. http://apps.who.int/iris/handle/10665/78660 (acessado em 05/Jul/2017).
http://apps.who.int/iris/handle/10665/78... , with the aim of minimizing potential risks of conflicts of interest that can negatively impact public health. In the field of public health, in 2017 the WHO established a framework for involvement in PPPs to orient the organization’s activities as to raising additional funds ³3. WHO engagement with non-state actors. http://www.who.int/about/collaborations/non-state-actors/en/ (acessado em 5/Jul/2017).
http://www.who.int/about/collaborations/... . In the authors’ opinion, this fact does not mean the dissolution of mechanisms for negotiating international agreements, conflict resolution, and consensus-making, but it adds another element that is reflected in the need to ensure that the work agenda of this and other agencies is not influenced or directed in a way inconsistent with the work plans approved by the General Assemblies. In addition to the conflict of interest already mentioned, there should not be any risk to the organization’s reputation due to corporate donations.

Guimarães’ comments raise relevant points and emphasize the need for an analysis of the historical and situational context leading to the discussion of PPPs, which is beyond this study’s scope. However, it appears plausible that the potential promotion of these partnerships may originate from the need for intergovernmental agencies to compensate for cuts in regular funding from their member states, particularly in the case of the specialized United Nations bodies, programs, and agencies. Possible indicators of this tendency include the establishment of the United Nations “Global Compact” ⁴4. United Nations Global Compact. https://www.unglobalcompact.org (acessado em 5/Jul/2017).
https://www.unglobalcompact.org... as the initiative in charge of promoting social accountability by the private sector. This trend was maintained in the promotion of partnerships that are part of the platform of goals in the Sustainable Development Agenda for 2030 ⁵5. United Nations Sustainable Development Goals 2030. http://www.un.org/sustainabledevelopment/globalpartnerships/ (acessado em 5/Jul/2017).
http://www.un.org/sustainabledevelopment... .

We thank Guimarães for so appropriately proposing the concept of “intent and gesture”. We believe that the former term is especially associated with the image many companies seek among the public at large as “socially committed”, an intent that does not generally lead to action, or the gesture in the second term.

Our article certainly does not exhaust the debate on PPPs, and various aspects of this process should be the target of future studies and proposals. A case-by-case assessment, as all the discussants suggest, could provide a better definition of what is expected from public-private partnerships.

Publication Dates