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With many countries facing scarcity of freshwater and farmable land, Brazil decided to leverage its wealth of both resources to attract global agribusiness players to the historically poor Sao Francisco Valley (SFV) in the country's northeast. To do so, Brazil was instituting its first public-private partnership (PPP) in irrigation at Pontal, a partially built irrigation project in the SFV. In exchange for partial reimbursement from the Brazilian government and free use of 30,000 hectares land for 25 years, the private-sector partner would finish constructing the irrigation infrastructure and establish agricultural operations on the project; the partner was also required to integrate some local smallholders into the production chain. In December 2009, Codevasf was almost ready to start accepting bids for Pontal. For Clementino de Souza Coelho, director of infrastructure for Codevasf, the stakes were high: if successful at Pontal, PPPs could be replicated throughout the SFV, transforming the historically poor region into an agribusiness hub, as well as be a model for the rest of the world.

Through its uniquely proactive approach to medical malpractice risk management, the Risk Management Foundation has decreased claims-and premiums-for the Harvard hospitals it insures. The RMF is the captive medico-legal insurer of the Harvard medical institutions and affiliated physicians. Over the last two decades, through a combination of active legal defense and medical error prevention, The RMF has successfully controlled the medico-legal costs of physicians practicing at the Harvard teaching hospitals; consequently, its insured physicians pay notably lower premiums than similar specialists outside the Harvard system. The RMF's success has been due, in large part, to the close working relationships it has cultivated with the insured physicians and hospitals. However, as the hospitals expand their networks into Boston's suburbs, new, less tightly affiliated doctors whose medico-legal risk is higher than those practicing at the hospitals are coming under RMF's umbrella. This case describes The RMF's approach to risk management and the challenges its managers face in accommodating these new physicians.

This case explores maximizing shareholder value as a goal in executive decision making. Over a period of nine years, three different Pfizer CEOs make critical decisions intended to increase shareholder value. But the results are disappointing. To allow students to examine these decisions, the case provides excerpts from four Chairman's letters to shareholders from Pfizer's annual reports, followed by a description of the circumstances behind each letter. In the 2000 annual report, then-CEO Bill Steere discusses Pfizer's rise to industry prominence with the acquisition of Warner-Lambert. In the 2003 report, new CEO Hank McKinnell discusses Pfizer's performance goals and its acquisition of Pharmacia, which gave it control of anti-arthritis drug Celebrex. In the 2005 report, McKinnell discusses his decision to keep Celebrex on the market despite health risks. In the 2006 report, new CEO Jeff Kindler barely mentions McKinnell's (controversial) early retirement and describes efforts to reform the company. The case closes in February 2009, just after Pfizer announces plans to acquire competitor Wyeth. Since 2000, Pfizer's tremendous growth in assets through acquisitions has not translated into significant growth in net income or share price. In closing, students are asked what Kindler should write in the letter to shareholders to open Pfizer's 2008 annual report.

How will Newton-Wellesley Hospital (NWH) preserve its private practice tradition while remaining effective and competitive in a healthcare industry demanding increasing integration between physicians and hospitals? This is the decision facing Newton-Wellesley Hospital president Mike Jellinek in 2009, as several trends-higher costs and lower revenues, shifting workforce demographics, and changing reimbursement models-threaten to disrupt NWH's organizational model. Similar to other U.S. community hospitals, NWH has historically been staffed primarily with private practitioners; however, in recent years Jellinek has taken several steps toward further integration, such as hiring primary care physicians and hospitalists, and even proposing formation of a physicians' organization (PO)-a move its veteran private practitioners sharply oppose. In 2009, NWH is renowned for high-quality care and is financially strong; yet, given external pressures, most at the hospital agree that reforms are needed to improve the hospital's and physicians' profitability while maintaining highest-quality patient care. Diverging opinions over how to improve the hospital has exposed differences between some private practice physicians and the administration. The crux of their disagreement centers on one question: how to make the organizational changes required to keep NWH effective and competitive in the face of a diminishing revenue growth rate, while honoring its tradition of physician independence.

This two-class case series allows students to stand in the shoes of CEO Ray Gilmartin during the unfolding stages of a reputational crisis. Merck's mission statement claims to "put patients first," but the company is widely criticized for putting profit before patient safety. The (A) case describes the discovery of Vioxx, a new arthritis drug, and asks students to calculate the drug's lifetime expected value. Supplements are handed out in class as the story unfolds: (B) evidence of life-threatening side effects, (C) decision options, (D) announcement to withdraw Vioxx, (E) reaction by patients, shareholders, media, and regulators, (F) Merck fights back, and (G) wrap-up. At the end of the case series, students may conclude that doing the right thing sometimes requires very hard choices.

Describes the Spine Center at Dartmouth-Hitchcock Medical Center, a multidisciplinary unit that offers patients suffering from spinal problems "one-stop" access to a range of providers including orthopedic surgeons, neurosurgeons, neurologists, medical specialists in physical medicine and pain management, mental health providers, and occupational and physical therapists. The Center was created to address what its founder, James Weinstein, M.D., saw as the uncoordinated and inefficient delivery of spinal care in the United States. The Center emphasized using non-surgical treatments (e.g., physical therapy and exercise, behavioral modification, pain-relieving drugs) as either a complement to, or substitute for, surgical procedures, and patients were actively engaged in the process of determining what type of care to pursue. In addition, Weinstein and his staff collected data from the Center's clinical practice to conduct academic research on the outcomes and cost-effectiveness of various approaches to treatment. The case allows for a critical analysis of the Spine Center's unique approach to care delivery and provides an opportunity to examine the applicability of this model in other clinical areas.

This case examines the strategy implementation and risk management decisions at Sydney IVF, a research-based in vitro fertilization and stem cell company based in Australia. Drs. Robert Jansen and Jock Anderson, who co-founded Sydney IVF in 1986, developed novel technologies which they leveraged to carve a leadership role in the inherently risky artificial fertilization business. As the company grew, its executives grappled with managing the political, ethical and business risks associated with the contentious lab-based fertility field, instituting sophisticated safeguards such as an independent ethics committee and a "whistle blower" system for employees concerned with the company's practices. In less than two decades, Sydney IVF grew from just four employees to over 200, expanded internationally, and broadened its services to include prenatal screening for genetic diseases and DNA tests to determine lineage and paternity. In addition, the company launched a wholly-owned subsidiary, the Stem Cell Company. CEO Robert Jansen hoped to grow the Stem Cell Company, but faced many challenges, including the significant ethical risks, challenging regulatory environment, and uncertain future of the stem cell field. The case describes how Jansen safeguards against risk without stifling the innovative spirit necessary to commercialize stem cells.

In 13 years, Bruce Taylor had built Taylor Fresh Foods into a $1 billion company and the top supplier of salads to the U.S. food service industry and to supermarket deli departments. In 2008, he was convinced that the time was right to make a big push in the fresh food area to satisfy consumers that were demanding more convenient, natural, good-tasting, and locally-grown foods. Bruce needed an action plan to make Taylor Fresh the industry leader before his competition woke up to the opportunity that lay before them all.