The Partnership Pathway: how it nearly fell apart
Chapter 2: Build Collaborations — Video 4
https://ghrbook.com/videos/the-partnership-pathway/

[Slide 1] This video is a case study — a partnership that changed global health policy, and very nearly fell apart on the way there.
[Slide 2] The principles we've covered sound straightforward on paper. But what does collaboration actually look like when the stakes are high, the partners span continents, and lives hang in the balance? Let me walk you through a real example, drawn from the book Real Collaboration, which documents — in the words of the people involved — how global health partnerships succeed, struggle, and sometimes nearly fail.
[Slide 3] As it unfolds, notice which principles show up. You'll see vision hold a partnership together when everything else frays. You'll see trust erode when turnover disrupts relationships. You'll see communication failures create confusion that better logistics could have prevented. And you'll see leadership that excelled at inspiration but struggled with management.
[Slide 4] In the late 1990s, multi-drug-resistant tuberculosis was widely regarded as untreatable at scale in resource-poor settings. The disease is resistant to the two most powerful anti-TB drugs available, and treatment requires simultaneously administering seven or eight expensive second-line drugs for eighteen to twenty-four months.
[Slide 5] The prevailing wisdom at the World Health Organization was that treating this form of tuberculosis in low-income countries was simply not programmatically feasible. Too complex, too expensive, and too likely to amplify resistance.
[Slide 6] Paul Farmer and Jim Kim of Partners in Health disagreed. Working with their Peruvian partner organization, Socios en Salud, they had begun treating patients in Lima using community health workers who watched patients take their medications daily and supported them through the brutal side effects.
[Slide 7] And here is a point worth sitting with. Socios en Salud's community-based model and local credibility were not an implementation detail — they were the engine of the early success. But funding was running out.
[Slide 8] What happened next offers a masterclass in how collaborations form, function, and sometimes falter. In 1998, Farmer and Kim approached their former dean at Harvard about funding possibilities. He suggested they contact Mark Rosenberg at the Task Force for Child Survival and Development. Rosenberg, in turn, brought in Bill Foege, who was transitioning to the Bill and Melinda Gates Foundation.
[Slide 9] When these four met, Foege pushed them to think bigger. Don't just treat patients in Peru — demonstrate that this approach could work in resource-poor settings anywhere. That evidence could change World Health Organization policy worldwide.
[Slide 10] That conversation didn't instantly create a partnership, but it aligned people who already trusted each other around a shared, scalable goal. From this convergence, the Partnership Against Resistant Tuberculosis was born, eventually bringing together Partners in Health, the CDC, the World Health Organization, the Task Force, and Peru's Ministry of Health, with funding from the Gates Foundation.
[Slide 11] Researchers who study global health collaborations have identified a common trajectory that partnerships follow — what Rosenberg and colleagues call the Partnership Pathway. If this sounds familiar, it should. Like Tuckman's model of team development, it maps the stages collaborations move through. But where Tuckman emphasizes interpersonal dynamics, the Partnership Pathway focuses on the operational work of building and sustaining a partnership.
[Slide 12] There are four stages. Genesis, where every partnership begins with a realization that individuals can make a difference if they work together. The First Mile, the critical early phase when partners establish their foundation. The Journey, when partners begin the hard work of implementation. And the Last Mile — achieving the goal, transferring knowledge and control, and knowing when to end.
[Slide 13] Like climbers at base camp preparing for an ascent, partnerships in the First Mile must choose the right membership, develop a truly shared goal, select an appropriate governance structure, shape a big-picture strategy, and clarify organizational roles. The First Mile is an opportunity that doesn't come again. Get these elements right, and you've built a foundation for trust. Skip them or handle them poorly, and problems will haunt you throughout the collaboration.
[Slide 14] PARTNERS handled their First Mile reasonably well. They kept membership small enough for real collaboration — just five core organizations, each with a clear role. Partners in Health and Socios en Salud provided treatment and collected clinical data. The CDC conducted research and set standards. The World Health Organization implemented the Green Light Committee and set policies. The Task Force served as neutral convener and facilitator. And Peru's Ministry of Health developed capacity for countrywide expansion.
[Slide 15] What was less clear — something the partners only appreciated later — was how those organizational roles translated into day-to-day decision-making among individuals. This distinction would matter. They did develop a shared goal: demonstrate the feasibility of treating this disease in resource-poor settings, which could then change global policy. And they created an innovative strategy, the Green Light Committee, which would negotiate lower drug prices in exchange for oversight of proper use.
[Slide 16] PARTNERS achieved their goal. But the journey was rocky, and the partners were remarkably honest about what went wrong. The first problem was underinvestment in management. Mark Rosenberg later reflected: we thought our challenge was to bring complex health interventions to resource-poor settings, but we realized the real challenge was delivering complex health interventions to management-poor settings. We didn't realize how important management was, or how big the management deficit was in all of us. Planning happened on the fly. Communication was inconsistent.
[Slide 17] Three more things frayed the partnership. Leadership was mismatched to the phase — Jim Kim was brilliant at articulating the vision, but the nine working groups never got traction and were eventually disbanded. Turnover eroded trust: after the first two years, key members rotated out, Kim left Partners in Health to join the World Health Organization, and some partners felt they were only going through the motions of collaboration. And then external force. In spring 2003, Peru's entire Ministry of Health was restructured in a single day, with a lag in drug supplies compounding the problem.
[Slide 18] The partners had been working with specific ministry officials to plan for sustainability, and suddenly they didn't know who was in charge. The partnership lacked the cohesiveness to respond with one voice. And it still succeeded. The next video is about why.