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Multistakeholder partnerships in global nutrition governance: protecting public interest?

Ann Louise Lie, Sabrina Ionata Granheim About the authors

Multistakeholder partnerships, involving public and private actors, have become key instruments in global food and nutrition governance. Such partnerships have the potential for conflicts between profit and public health goals, which may harm the integrity of nutrition policy. How can conflicts of interest be adequately addressed, and by whom?

Multistakeholder partnerships involving governments, international organisations, civil society and private sector actors have become key instruments for implementing the 2030 Agenda and the Sustainable Development Goals. In food and nutrition governance, such partnerships have proliferated as mechanisms to address the multiple burdens of malnutrition, from hunger and undernutrition to obesity and diet-related non-communicable diseases. While promoted as effective responses to complex development challenges that require expertise and resources from multiple sectors, partnerships between public and private actors can create tensions between profit motives and public health goals. Businesses whose profit depends on marketing and sales of unhealthy food and beverages may for example contribute to reframe malnutrition problems in their own interests (e.g. as the result of individual behaviour only), influence public health agendas and priorities, and interfere with legislative processes to derail industry regulation. Such undue influence may, however, be overcome through effective prevention and management of conflicts of interest. The question is how, and who should be responsible for developing ‘the rules of the game’?

In order to explore these questions, we discuss the respective roles of the World Health Organization (WHO) and the Scaling Up Nutrition Movement (SUN Movement) in providing normative guidance for governments on how to protect nutrition policy from undue influence. The SUN Movement was established in 2010 as a global multistakeholder partnership for nutrition, involving governments, international organisations, business, civil society organisations and private donors, committed to supporting 59 developing countries in their efforts to reduce undernutrition. While WHO has been mandated by its Member States to develop guidance on conflicts of interest in nutrition, the SUN Movement has developed its own guidance for its member countries. Rather than protecting the integrity of public sector agencies, the guidance of the SUN Movement seems primarily to aim at protecting the inclusiveness of the multistakeholder process. This not only risks undermining public health priorities, but also the authority and legitimacy of WHO’s role as a norm-setting agency.

What are conflicts of interest?

Thompson defines conflicts of interest as ‘a set of conditions in which professional judgment concerning a primary interest (such as a patient’s welfare or the validity of research) tends to be unduly influenced by a secondary interest (such as financial gain)’ (1, p. 573).

Conflicts of interest can occur at different levels; for instance, at institutional level, when an organisation has financial ties that conflict with its vision and mission; or at the individual level, when a financial interest may impair an individual’s (e.g. health professional’s, civil servant’s) ability to make a judgement in the public interest. Both institutional and individual conflicts of interest can damage public trust in and the credibility of public sector officials or agencies, and undermine the quality of policies and services they deliver.

Conflicts of interest in global food and nutrition governance

As private sector actors have gained increased influence in nutrition policy through participation in partnerships with governments, many have raised concerns about the need to safeguard nutrition policy-making from undue influence (2,3). While partnerships may provide effective solutions to policy problems by drawing on skills and resources from different stakeholders, there should be a limit to the level of involvement of actors whose interests conflict, or may seem to conflict, with public agencies’ agendas. Actors that arguably should be kept at arm’s length when food and nutrition policy is developed are for example businesses that profit from marketing and sales of products harmful to health. Negative health impacts are widely recognised in the case of heavy marketing and widespread use (beyond what is medically recommended) of breastmilk substitutes, and extensive marketing of food products rich in salt, sugar and fat to children (4,5).

WHO’s efforts to prevent and manage conflicts of interest in nutrition

Through the endorsement of the Comprehensive implementation plan on maternal, infant and young child nutrition by Member States in 2012, WHO was mandated to ‘form alliances and partnerships to expand nutrition actions with the establishment of adequate mechanisms to safeguard against potential conflicts of interest’ (6). Member States also mandated WHO to ‘develop risk assessment, disclosure and management tools to safeguard against possible conflict of interest in policy development and implementation of nutrition programmes consistent with WHO’s overall policy and practice’ (6).

Since then, WHO has adopted a policy to guide its engagement with non-state actors (7) and is currently working to develop guidelines for countries on prevention and management of conflicts of interest in the nutrition policy process. The guidelines will be presented at the World Health Assembly in 2018. When adopted, they should serve as authoritative advice to governments on how to engage with non-state actors without compromising the integrity of health authorities or nutrition goals. However, in a number of countries burdened by high levels of malnutrition, WHO’s guidelines are at risk of being undermined even before dissemination, by alternative guidelines developed by the SUN Movement.

The SUN Movement’s approach to conflicts of interest

What is the role of the SUN Movement? In contrast to WHO, the SUN Movement is not a specialised UN agency whose role is to perform normative and analytical functions mandated by Member States. Rather, the SUN Movement has the self-appointed role of coordinating nutrition actors at the global level, advocating for and mobilising funding for nutrition, and supporting country-level action in the area of malnutrition. One of its key aims is to establish multistakeholder partnerships for nutrition within its member countries (8).

The close involvement of food corporations in these partnerships raises concerns about whose interests are promoted through the SUN Movement. Initially focused on reducing stunting (low height for a child’s age), the SUN Movement has recently broadened its scope to reduce all forms of malnutrition, including overweight and obesity (8). This aim seems to conflict with the interests of many of the food corporations involved. Through its Business Network, 268 companies have committed to supporting countries’ efforts to scale up nutrition action (9). Among these, a large number of corporations selling products harmful to health, such as Coca-Cola, PepsiCo and Mars, are members and represented on the Movement’s governance boards (10).

In 2013 and in parallel to WHO’s ongoing work on conflicts of interest in nutrition, the SUN Movement started to develop guidelines for its member countries on how to address such conflicts. The guidance, A Reference Note and a Toolkit for Preventing and Managing Conflicts of Interest, was financed by the private Bill and Melinda Gates Foundation, and developed by a private consultancy firm (11). This guidance has been widely disseminated within the SUN Movement’s 59 member countries and is currently being used by its members, including the Business Network, to guide governments’ efforts to address conflicts of interest when developing their nutrition policies and programmes.

While this might seem like a welcome development and proactive response by the SUN Movement to prevent conflicts of interest from arising within the partnerships it promotes, a closer look at the guidance raises concerns regarding its intentions and the appropriateness of its interference with WHO’s norm-setting role.

Concerns regarding the SUN Movement’s conflicts of interest guidance

There are several reasons why the SUN Movement’s guidance on conflicts of interest is problematic. Firstly, the purpose of the guidance does not seem to be to protect the integrity, independence and public trust in individuals and institutions serving public interests, but rather to ensure effective functioning of the partnership itself and to strengthen inclusion of new partners (12, p. 14). The definition applied is unclear and states that a conflict of interest arises when a secondary interest conflicts with the aims of the partnership, which in the case of the SUN Movement is to promote multistakeholder collaboration. It also states that it is important to manage conflicts of interest ‘because it can promote inclusiveness in recruiting and working with stakeholders. (…) and contributes to the effectiveness of the collective effort’ (12, p. 18).

Secondly, the SUN Movement’s guidance confuses conflicts of interest with concepts such as ‘diverging interests’ between different actors, and by suggesting that any type of collaboration can lead to conflicts of interest, downplaying the concern about conflicts arising between primary and secondary interests (for example public health versus profits) within an institution or an individual. The guidance also underplays the significance of conflicts of interest by distinguishing between actual and perceived conflicts of interest. The concept of ‘perceived’ conflicts of interest suggests that a conflict of interest only arises if actual bias or harm to public health occurs. This is misguided and opens up for treatment of perceived conflicts of interest as less serious (13). Indeed, the SUN Movement’s guidance states that perceptions of conflicts of interest only sometimes merit an intervention (12, p. 14).

Thirdly, many of the principles of engagement upon which the guidelines are based conflict with an effective conflict of interest policy. Of particular concern are the principles ‘to be inclusive’ and ‘to be willing to negotiate’ (12, p. 11). In order to avoid undue influence on public policy-making, exclusion of actors with perceived or actual conflicts of interest is sometimes necessary, and there is not always room for negotiating ways around it. However, the guidance of the SUN Movement encourages to ‘limit the scope and duration of any exclusionary decision’ (12, p. 21) on the grounds that it contradicts the principles of the partnership. If multistakeholder partnerships mean that the principle of inclusion must be followed above all else, this model is not reconcilable with effective prevention or management of conflicts of interest. The principle of inclusiveness is also problematic, as it does not recommend any limitation to the involvement of non-state actors at any point in the policy process. Having committed to being members of the SUN Movement, governments’ abilities to withstand pressure and attempts at industry interference may be undermined, as well as their political power to decide on the extent to which private actors should be allowed into policy-making processes, and at which stage.

The SUN Movement’s principle number 5, ‘to be predictable and mutually accountable’ is also problematic as it suggests that governmental and non-governmental actors alike have equal responsibilities. While every partner has a role in a partnership, the roles and responsibilities of the various actors are not at the same level. Most importantly, governments are primarily accountable to citizens, not to other members of such partnerships.

Finally, the SUN Movement’s guidance is weak in the measures it proposes to prevent and manage conflicts of interest. It recommends protection of confidentiality and privacy in the disclosure process (12, p. 18), which contradicts the principle of transparency. Rather than ensuring an independent process, the guidance recommends that ‘Mechanisms for managing conflicts of interest should include all stakeholders – including those with a perceived or potential conflict of interest’ (12, p. 20). This will seriously limit the effectiveness of a conflicts of interest policy.

These issues indicate that the SUN Movement’s Reference Note and Toolkit do not provide an appropriate or sufficient response to the very real question of how to protect food and nutrition policy-making from undue commercial influence. Rather than providing clear advice to governments on how to address conflicts of interest while engaging in partnerships, the SUN Movement’s guidance seems to encourage inclusiveness above all else, without any risk assessment. This contributes to governments’ existing confusion about when and how to enter into partnerships, and may even legitimise engagements that clearly create conflicts of interest. Additionally, the overlap with WHO’s work on country guidance on conflicts of interest may lead to slower and weaker measures to protect nutrition, and an additional burden on already overstretched government staff.

Protect democratic processes

While multistakeholder partnerships have the potential to draw on resources and skills from different actors in order to improve effectiveness of nutrition interventions, they create real risks and challenges to food and nutrition policy-making that need to be acknowledged and appropriately addressed.

The Scaling Up Nutrition (SUN) Movement (14)

  • Established in 2010.

  • A global multistakeholder partnership for maternal and child malnutrition.

  • Members include UN system organisations, civil society organisations, businesses, private foundations, bilateral donors and 59 developing countries.

  • Stakeholders are organised into four networks: donors, business, civil society and the UN.

  • Led by a global multistakeholder Lead Group and an Executive Committee.

  • Promotes multi-sector and multistakeholder partnerships for nutrition in SUN countries.

  • Aims to scale up evidence-based nutrition-specific and sector-wide approaches to nutrition in member countries.

The analysis of the SUN Movement’s guidelines on how to prevent conflicts of interest suggests that organisations with a self-interest in promoting multistakeholder partnerships should not provide normative guidance to governments on how to protect public health from undue influence. The SUN Movement conveys a misguided understanding of what ‘conflicts of interest’ means and contributes to undermine the authority of member-state mandated organisations such as WHO, and of governments themselves.

The fact that the SUN Movement promoted a parallel process to that of WHO on conflicts of interest can be seen as an attempt to establish norms of engagement in line with its own agenda that downplays the risks of stakeholder engagement. Rather than protecting the institutional integrity and independence of public sector agencies, the SUN Movement is legitimising its own mission through its guidelines. Over time, this can lead to reduced public trust in public health agencies, and be an impediment to the fulfilment of existing international nutrition goals, including those in the Sustainable Development Goals. Rather than uncritically promoting multistakeholder partnerships for food and nutrition, more efforts should be made to protect democratic processes and prevent corporate influence on public policy.

This article is part of the series ‘Global Health in the Era of Agenda 2030’, a collaboration between Norad, the Centre for Global Health at the University of Oslo and The Journal of the Norwegian Medical Association. Articles are published in English only. The views and opinions expressed in the articles are those of the authors only.

1

Thompson DF. Understanding financial conflicts of interest. N Engl J Med 1993; 329: 573 - 6. [PubMed][CrossRef]

2

Marks JH. Toward a Systemic Ethics of Public-Private Partnerships Related to Food and Health. Kennedy Inst Ethics J 2014; 24: 267 - 99. [CrossRef]

3

Gomes FS. Conflicts of interest in food and nutrition. Cad Saude Publica 2015; 31: 2039 - 46. [PubMed][CrossRef]

4

Grover A. Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. Human Rights Council A/HRC/26/31. 2014. http://www.who.int/nmh/events/2014/rapporteur.pdf (14.7.2017).

5

Piwoz EG, Huffman SL. The Impact of Marketing of Breast-Milk Substitutes on WHO-Recommended Breastfeeding Practices. Food Nutr Bull 2015; 36: 373 - 86. [PubMed][CrossRef]

6

 . World Health Organization. Comprehensive implementation plan on maternal, infant and young child nutrition. World Health Assembly Resolution WHA65.6. 2012. http://www.who.int/nutrition/publications/CIP_document/en/(12.7.2017).

7

World Health Organization. Framework of engagement with non-state actors. World Health Assembly Resolution WHA69.10. 2016. http://www.who.int/about/collaborations/non-state-actors/A69_R10-FENSA-en.pdf?ua=1 (12.7.2017).

8

 . SUN Movement. Strategy and Roadmap 2016 – 2020. 2017. http://docs.scalingupnutrition.org/wp-content/uploads/2016/09/SR_20160901_ENG_web_pages.pdf(19.7.2017).

9

SUN Business Network. SUN Business Network Company Commitments. 2017. http://sunbusinessnetwork.org/wp-content/uploads/sites/2/2015/01/SUN-Business-Network-Company-Commitments-09-Jan-2017.pdf (14.7.2017).

10

Global Alliance for Improved Nutrition. SUN Business Network. 2017. http://www.gainhealth.org/about/global-platforms/sun-business-network/ (19.7.2017).

11

SUN Movement. Preventing and Managing Conflicts of Interests: Background. 2015. http://scalingupnutrition.org/share-learn/multistakeholder-engagement/preventing-and-managing-conflicts-of-interest/ (20.7.2017).

12

Global Social Observatory. Engaging in the SUN Movement: Preventing and Managing Conflicts of Interests. Reference Note and Toolkit. 2015. http://docs.scalingupnutrition.org/wp-content/uploads/2014/05/Reference-Note-and-Toolkit-English.pdf (14.7.2017).

13

Lo B, Field MJ, red. Principles for Identifying and Assessing Conflicts of Interest. In: Conflict of Interest in Medical Research, Education and Practice. National Academies Press: Washington, DC, 2009. https://www.ncbi.nlm.nih.gov/books/NBK22937/ (11.10.2017).

14

SUN Movement. Scaling up nutrition. http://scalingupnutrition.org/ (9.10.2017).

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