PHM-Exch> Multistakeholder partnerships in global nutrition governance: protecting public interest? The SUN Mo vement

[Claudio Schuftan]

Multistakeholder partnerships in global nutrition governance: protecting
public interest? | Tidsskrift for Den norske legeforening

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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.

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.





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 policymaking

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.
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