Public health sector and food industry interaction: it's time to clarify the term 'partnership' and be honest about underlying interests

In the context of concerns about unhealthy diets, obesity and chronic diseases in Europe and around the world, the food industry is making a growing number of pledges to be ‘part of the solution’. Governments, too, are looking for ways to promote healthy eating at the population-level. Emerging in this environment are initiatives that bring together the food industry and institutions of the state, increasingly described as ‘partnerships’ or ‘public–private partnerships’. By working together, so the rationale goes, public and private sector bodies can more effectively achieve shared goals than could have been achieved alone, reach consensus about needed action, pool expertise, ideas, skills and resources, reach a broader range of populations, and reduce the costs of regulation.1 Although some academics, professionals and policy-makers have concerns or are cautious about these initiatives,2 partnerships have seemingly become de rigueur. The public health commissioner of the European Union (EU) said in 2006: ‘You cannot legislate on what people eat. You have to form public–private partnerships. We are all… part of the problem and are all part of the solution.’ First Lady Michelle Obama describes her anti-obesity initiative, ‘Let’s Move’, as a ‘public–private partnership that, for the first time, sets national goals to end childhood obesity in a generation’. At the global level, the World Health Organization’s 2008–13 Action Plan for Non-Communicable Diseases explicitly calls for the involvement of the private sector as one of the international ‘partners’. Industry leaders, meanwhile, are suggesting that ‘only through new and innovative public–private sector partnerships can we truly make a difference’.3 As public health officials nod their heads in support of ‘partnerships’ with the food industry, what are they actually talking about? For when we start looking more closely at existing examples, we see ‘partnership’ means a whole lot of things. Take EPODE, the ‘partnership’ that tackles obesity through educational activities in schools in France and some other European countries. The dominant (albeit not only) aspect of the public–private interaction in EPODE is funding—mainly from private to public. But in other cases, the ‘partnership’ involves funds changing hands in the other direction. The Scottish Grocers Federation’s Healthy Living Programme, for example, is financed by government. Other so-called partnerships involve joint funding, such as the Diet and Health Research Industry Club (DRINC) in the UK, in which both government and industry pool research money for projects to develop new or reformulated foods. Many ‘partnerships’ do not involve funding at all. Some are simply platforms for discussion among ‘partners,’ such as the development of the food and nutrition strategy in Finland, and the ‘Dialogue Forum’ concerning obesity in Sweden. Other self-proclaimed partnerships also involve discussion, but are characterized above all by ‘targets’ set by the public sector for the private sector to achieve. Salt reduction initiatives in France, Ireland, Spain and the UK provide examples. In others, the private sector makes ‘commitments’ to the public sector, such as the Covenant on Overweight and Obesity in the Netherlands. ‘Partnerships’ can also refer to dedicated organizational structures (board, staff, rules, etc) established to manage cooperation between public and private sectors. While a number of such organizational structures exist in other areas of public health at the global level,4 there are no similar global structures concerned with healthy eating, and scant examples at the national level. The Top Institute for Food and Nutrition in the Netherlands conducts research to develop and reformulate food products and has an executive board with representatives from the public and private sectors and funding from both sectors. The Platform for Nutrition and Exercise in Germany is an independent entity with food industry and government representatives on its steering board (funded by membership fees). In other cases, partnership does not extend to forming an organization as such, but involves an explicit shared governance structure hosted by one of the partners. Notable examples include the Danish ‘Six a Day’ and ‘Wholegrain’ campaigns, both hosted by the Danish Cancer Society, but each with a board of directors comprised of private and public sector representatives, with funding from all parties. In the UK, the ‘Responsibility Deal’ is hosted by government but involves both sectors making decisions about food industry pledges to improve the food environment. At a local scale, Health4Schools in the UK is hosted and funded by Kraft Foods, yet is guided by a steering committee with joint representation. So, when officials and others talk about ‘partnerships,’ they are, in fact, talking about a whole mélange of interactions involving a range of different activities, from education campaigns to joint research activities, and a range of processes and structures for interaction. Yet there is an important distinction that can be made: interactions characterized by ‘shared decision-making power among partners’ and those characterized simply by ‘participation’ from both sectors. In the former, both sectors play a role in decisions about the agenda, goals, strategies, resources, roles and responsibilities of the initiative; in the latter, there may be mutual support, but no shared decision-making.4 The distinction between ‘partnership’-based and ‘participation’-based initiatives may appear academic and even immaterial given that influence in decision-making can be exerted in the absence of formal structures for decision-making. Still, making the distinction is critical. For a start, using the term ‘partnership’ imprecisely can create misleading expectations. For example, a public sector-led initiative may embrace private sector actors as ‘partners’ even when its only interest is gaining private sector concessions or funding with few or no conditions. But by giving the impression to the private sector that it is a real ‘partner’, the public sector is, like it or not, inviting for-profit actors to use the arrangement to serve their own private sector interests. The indiscriminate use of the term ‘partnership’ is also misleading for civil society. Although many non-governmental organizations, researchers and professionals routinely collaborate with the private sector, many are unwilling to enter into ‘partnerships’ because of real or perceived conflict of interests and perceptions of compromised independence. If public health officials want to draw on the potential power of civil society to serve their interests, they would be advised to be clearer about when they need civil society ‘participation’ in an initiative, or actual ‘partners’. Private sector-hosted ‘partnerships’ would be advised likewise. Describing, for example, the presence of a public sector official on an advisory board of a private-sector initiative as a ‘partnership’ will likely lead to loss of legitimacy when it becomes obvious that the decisions are actually made by the private sector. Importantly, using the term ‘partnership’ about participation-based interactions also muddles the discourse about ‘good governance’ of public–private interactions—an issue that often arises due to conflict of interest concerns. One of the core aspects of ‘good governance’ of any initiative is the representation and participation of those affected by the exercise of power.4 From this perspective, partnerships that do not have joint representation by the public and private sectors on governing bodies could be viewed as ‘poorly governed’. Yet in other cases, the exclusion of private sector representatives from decision-making processes may represent good governance if it avoids conflict of interest and/or threats to the host sector’s interests. An apparent tension thereby surfaces among different aspects of good governance of ‘partnerships’—participation and representation in decision-making on the one hand and upholding legitimacy and accountability on the other. Thus taking an overly generic definition of ‘partnership’ means that what constitutes ‘good governance’ cannot be definitively specified ex ante, key factors of successful collaboration become difficult to identify and ‘models of best practice’ become less meaningful. What is needed, then, is for the term ‘partnership’ to be used when it is accurate to do so; namely, when the interaction involves both sectors having a voice in shared decision-making. If not, public–private ‘interaction’ or ‘engagement’ suffice. And in true partnerships, we need more honesty and transparency about what we mean by ‘interests’. It is often said that public–private partnerships are alright as long as the ‘public interest comes first’ (e.g. Uauy5). The problem with this argument is that it is unlikely that a real partnership would be sustained if the underlying ‘interests’—the often unstated but very real motivations for entering into an initiative, reflecting the benefits the participant hopes to gain—were not equally served, whether this be advancing business in the case of the private sector, or, in the case of the public sector, enlarging bureaucratic spheres of influence, making new contacts or securing a higher visibility for public officials or programmes. It would be naïve for public health practitioners to believe otherwise. It is thus disingenuous to try to put any so-called public health interest first. Importantly, though, the public health objective can (and should) come first (such as increased fruit and vegetable consumption etc). Public–private interactions to promote healthy eating now assume a role in the exercise of power that affect decisions about how to address unhealthy eating and associated public health outcomes. They are thus not to be taken lightly. As their development gains pace, public health policy makers can and must continue their role in setting public health objectives. This is simply not an appropriate role for the private sector who are not, after all, public health officials. When it comes to public–private engagement for healthy eating, it is only after the public health objective has been set that policy makers should even think about engaging with the food industry. They then need to ask themselves three questions: (1) Would engaging with the food industry help achieve the objective faster and more effectively? (with an answer likely to vary depending on the activities involved); (2) Would the interests involved (on both sides) enhance or threaten the likelihood of achieving the specific objective as well as longer-term public health objectives?; and (3) If interaction is a viable option, what form of engagement would most effectively achieve the objective while accounting for the different interests: a real partnership or a looser form of interaction? Serious engagement with these three questions will lead to greater clarity and a more constructive framework for the public health community to enter into this new era of food, diet and health governance and better shape it to deliver public health objectives. The global crisis of diet-related chronic diseases demands nothing less. Corinna Hawkes received a paid commission from the European Commission (EC) (via Tamarack Ltd) to prepare a report on public–private partnerships. This viewpoint reflects the points made in that report, but is in no way connected with the views with the EC or UNAIDS. The preparation of this viewpoint was based on a report prepared for the European Commission on public–private partnerships, and furthered by a presentation on partnerships made to a meeting concerning the Scottish Government Food And Drink Policy. The authors would like to thank Morten Strunge Meyer, Jacqui Webster, and Nina Christiansen for their comments on earlier drafts.