Glaxo Smith Kline (GSK) is one of the biggest players in the pharmaceuticals industry in Africa.

In the early 2000s, pharmaceutical companies were high on activists’ hit lists, prompted by Big Pharma’s ill-advised attempt to sue the South African government for patent infringement on HIV drugs; an attempt to deal with the country’s epidemic by allowing cheaper, generic copies to be sold.

Today, the discourse seems merrier. Charities and NGOs sit down with the same companies, discussing how best to confront public health challenges in the developing world. The talk is of partnerships and “˜win-wins’. 0It isn’t all idle chatter. Drug donations, reinvestment of profits in developing countries and a more flexible approach to intellectual property have all signalled a more collaborative approach from industry with the likes of GlaxoSmithKline, Sanofi, Johnson and Johnson and Merck all performing well in the 2012 Access to Medicine Initiative.

But while talk of a new era of friendship is appealing (not least to the companies), there are still unresolved debates about the role that companies play in shaping the public health agenda in developing countries. Even the most seemingly charitable acts have come under scrutiny.

Take drug donations. While giving people free medicine might seem a sure-fire winner for corporate PR and the world’s poor, some practitioners have reservations. Firstly, donations may focus the public health community on interventions for which companies have cures – albeit donated ones – without sufficient consideration of cost effectiveness, opportunity cost or prioritisation. Such factors are relevant, as free donations can lock governments and donors into particular programmes which they later have to fund themselves.

One example is the HPV vaccination programme for cervical cancer in Rwanda, enabled by a donation from Merck. After three years, the freebies expire, but Merck promised to provide Rwanda with a discounted access price to the vaccine. Assuming donors and governments pick up the bill, the donations could be interpreted as market-priming – creating the conditions for adoption – rather than corporate citizenship.

This might not be a problem if it were a drug for TB, malaria or AIDS – but critics of the HPV donation asked why cervical cancer received such a comprehensive effort in Rwanda – reaching 95 percent for 11 year old girls –  when disease incidence lags well behind other vaccine-preventable diseases in the developing world (see here for the Rwandan health minister’s persuasive rebuttal).

Others point out that while Rwanda’s HPV coverage rates are laudable, other basic interventions – from tackling diarrhoea or ensuring women are provided with medical experts during childbirth – are  still behind, raising questions about prioritisation.

As any public health official will tell you, there are no end of worthwhile diseases to tackle. The plight of a health ministry is making the difficult choices about what gets resources, and what does not. Critics say there are no – or not enough – comprehensive cost-effectiveness studies around donations. For cervical cancer, for instance, screening and treatment were considered by some to be more favourable options on a cost-effectiveness basis.

Some public health experts believe that “˜pull’ (incentives) mechanisms might be a better way of bringing the private sector compared to “˜push’ measures likes donation programmes. One example is the Advanced Market Commitment tool, where donors pledge to purchase developing country disease-focused vaccines or medicines, giving companies a commercial buyer and thus a reason to risk their R&D investment and product development. The mechanism “removes uncertainty for donors, governments, and vaccine manufacturers and improves availability and access” says Peter Shelby, associate director of communications at the International Federation of Pharmaceutical Manufacturers and Associations.

GSK’s pneumococcal vaccine – introduced in Kenya’s national immunisation programme in 2011 – benefited from AMC. But it was already a late-stage product, and AMC has not yet been used again. “Channelling such money should not be a problem from a [donor] Ministry of Finance or Treasury point of view, because they are such small amounts of money – you can’t imagine the US or UK couldn’t do that when the time comes,” says Amanda Glassman at the Center for Global Development in Washington.

But for companies to believe the money is real rather than a mere pledge by aid ministers, it has to be locked away safely. In the current climate of austerity, the idea of unused public money is not appealing for Western taxpayers, notes Glassman. And some governments – notably the US and Japan – have trouble participating in multi-year commitments that represent a fiscal contingency.

No-one should expect Big Pharma to act as a charity – for one thing, such behaviour will be superficial and unsustainable. The challenge is to establish where “˜corporate citizenship’ stops and the bottom line starts. As the recent intellectual property rights clash with Novartis in India shows, the “˜people over profit’ debate has not yet been dispensed with.

Adam Robert Green is senior reporter with This is Africa, a publication from the Financial Times.