Reposted from The Lancet
When decisions are made that will impact on people’s health, who should be represented at the policy-making table? Is it sufficient to rely upon representatives from national governments, or should other stakeholders participate—and if so, to what purpose? To advise? Make decisions? Or as funders? These questions lie at the heart of a governance debate1 that has been rancorously discussed in relation to WHO for some years. In May, 2016, the World Health Assembly (WHA) reached consensus in a resolution known as FENSA (Framework of engagement with non-State actors): “WHO engages with non-State actors….to encourage [them] to…protect and promote public health”, in which non-State actors are “non-governmental organizations [NGOs], private sector entities, philanthropic foundations and academic institutions”.2
FENSA had a difficult gestation, but is seen by many as a crucial element of WHO reform. Member States were generally supportive of FENSA, but NGOs voiced concern that FENSA will increase “problematic entanglements between WHO and powerful private sector actors”, and were disappointed that it did not “acknowledge the different nature—and thus different roles—public and private sector actors should play in global health governance”.3 By contrast, the private sector International Federation of Pharmaceutical Manufacturers and Associations welcomed the framework as giving “an equitable voice to a vibrant community of public and private organizations whose shared goal is to make this world healthier”.4
Concerns have long been raised about potential and actual conflicts of interest arising from WHO’s engagement with non-State actors, particularly in relation to organisations with a mandate based on the pursuit of profit rather than public health. WHO has acted upon these concerns with conflict of interest statements for expert advisers and will not engage with the tobacco and arms industries. Yet problems have arisen. A Reuters investigation in 2012, for example, found not only that the Pan American Health Organization had accepted money from companies such as Coca-Cola, Nestlé, and Unilever, but also that at least two of the 15 members of WHO’s Nutrition Guidance Expert Advisory Group had financial ties to the food industry.5 The flow of people between the private and public sector, including secondment to WHO, raises questions of influence and impartiality. Such influence does not only concern industry. Philanthropic foundations can also have an influence and potential conflicts of interest. For example, in 2015 the charitable UN Foundation placed a staff member in the WHO Director-General’s office for a 2-year period; and the Bill & Melinda Gates Foundation seconded a manager to the WHO Polio and Emergencies Cluster.6, 7
The FENSA resolution recognises the risks of potential conflicts of interest from engagement with non-State actors, including undue influence in setting or applying policies, norms, and standards. FENSA proposes mechanisms to avoid and manage these risks in the interests of public health—for example, through transparency, enhanced procedures, and staff training. Moreover, the FENSA resolution sets out specific guidelines in relation to distinct forms of engagement with each category of non-State actor.
FENSA is a necessary but insufficient response to the part the private sector plays in determining population level health outcomes. FENSA specifically mentions non-communicable diseases (NCDs), which are now the world’s leading cause of disability and death, but does not propose any mechanisms by which the private sector’s actions in the production and marketing of commercial products can and should be governed. The links between the pursuit of profit and negative health outcomes associated with processed foods, alcohol, tobacco, and air pollution have been extensively described.8, 9 WHO could have used the opportunity to leverage its mandate and authority to address the larger issue of governing the activities of industry, but FENSA focuses narrowly on the questions of risk assessment and management for WHO itself when engaging with the private sector. We are concerned that due diligence to protect WHO, even if well implemented, will not necessarily translate into improved corporate practices at global and national levels that will act to promote and protect the health of their consumers.
The relationship between public and private authority sits at the core of how we achieve NCD-related goals, and the governance of commercial determinants is crucial to disease prevention. Do we rely upon self-regulation by industry (eg, marketing codes or voluntary initiatives to reduce harmful exposure), co-regulation of the industry activities (eg, public sector partnerships with the private sector are an overarching approach within WHO’s 2013–2020 Global Action Plan on NCDs10), or public regulation of private sector activities?11 The latter approach is frequently promoted by the public health community as the preferred option—for example, in relation to the UK’s Responsibility Deals, the President of the UK Faculty of Public Health wrote that “There is no evidence that the ‘softly softly’ approach of engaging with industry rather than using legislation to improve people’s health has been more effective or quicker…sometimes the state has to step in to protect people.”12 Nonetheless, governance scholars13 question the effectiveness of this model because of the problems of industry subversion of public health goals and the challenges of enforcing regulatory measures.
WHO and its governing body have taken an important step in democratising the invite list to the policy table and establishing the dining etiquette. Now WHO needs to jump decisively off the right side of the fence and take more impactful measures, globally and nationally, to protect the health of the public by supporting governments and their partners to govern the health impact of industry. This approach will entail a shift from treating this issue as a technocratic and managerial project to the political one that it patently is. One part of this project involves embracing the public interest NGOs, which WHO has too long treated as adversaries, as the partners it needs—for they will be indispensable in generating both public support and political incentives to induce national leaders to take the difficult steps required to stand up to industry.
Sarah Hawkes and Kent Buse
- Bexell, M, Tallberg, J, and Uhlin, A. Democracy in global governance: the promises and pitfalls of transnational actors. Global Governance. 2010; 16: 81–101
- WHO. Framework of engagement with non-State actors. Sixty-ninth World Health Assembly, Agenda Item 11.3. World Health Organization, Geneva; 2016http://apps.who.int/gb/ebwha/pdf_files/WHA69/A69_ACONF11-en.pdf. ((accessed June 30, 2016).)
- Lhotská, L and Gupta, A. Whose health? The crucial negotiations over the World Health Organization’s future. Asia & the Pacific Policy Society, ; May 19, 2016http://www.policyforum.net/whose-health/. ((accessed June 29, 2016).)
- International Federation of Pharmaceutical Manufacturers Associations. WHA 69, item 11.3 Framework of engagement with non-State actors. Statement from International Federation of Pharmaceutical Manufacturers Associations. http://www.ifpma.org/wp-content/uploads/2016/05/IFPMA-Statement-11.3-NSA-May-2016-final.pdf; May, 2016. ((accessed June 29, 2016).)
- Wilson, D and Kerlin, A. Special report: food, beverage industry pays for seat at health-policy table. Reuters. http://www.reuters.com/article/2012/10/19/us-obesity-who-industry-idUSBRE89I0K620121019; Oct 19, 2012. ((accessed June 30, 2016).)
- Third World Network. WHO: unease over seconded philanthropic foundation staff to top management. Third World Network, ; December, 2015http://www.twn.my/title2/health.info/2015/hi151202.htm. ((accessed June 29, 2016).)
- Stuckler, D, Basu, S, and McKee, M. Global health philanthropy and institutional relationships: how should conflicts of interest be addressed?. PLoS Med. 2011; 8: e1001020
- Stuckler, D and Nestle, M. Big food, food systems, and global health. PLoS Med. 2012; 9: e1001242
- Beaglehole, R, Bonita, R, Horton, R…, and for the Lancet NCD Action Group and the NCD Alliance. Priority actions for the non-communicable disease crisis. Lancet. 2011; 377: 1438–1447
- WHO. Global action plan for the prevention and control of NCDs, 2013–2020. World Health Organization, ; 2013
- Buse, K and Naylor, C. Commercial health governance. in: K Buse, W Hein, N Drager (Eds.) Making sense of global health governance. Palgrave Macmillan, London; 2009: 187–208
- Faculty of Public Health, UK. FPH withdraws from responsibility deals. http://www.fph.org.uk/fph_withdraws_from_responsibility_deals; July 15, 2013. ((accessed June 29, 2016).)
- Abbott, K and Snidal, D. Taking responsive regulation transnational: strategies for international organizations. Regulation and Governance. 2013; 7: 96