Conducting workshops such as this one, as well as those mentioned in Chapter 1, is a good first step to building public–private partnerships in food and nutrition. This particular meeting created a safe space for representatives from different sectors not only to become more familiar with each other’s deeply held beliefs and goals for public–private partnership and explore the possibility of collaboration, but also to develop an understanding of processes and actions necessary for moving forward. This chapter summarizes the presentations and discussions that led to this understanding.
Specifically, workshop participants spent a great deal of time discussing and testing a draft assessment tool to use when making decisions about whether to enter a new partnership. The second breakout session was aimed at identifying which features of the tool would likely be most helpful. During the third breakout session, participants used the tool to guide their exploration of possibilities for public–private partnership in specific areas of food and nutrition (i.e., obesity, food labeling and messaging, calorie reduction). There was also a brief discussion on the importance of having a mechanism in place for opting out of an existing partnership.
Additionally, Jonathan Marks offered suggestions for how to navigate the ethics of private sector engagement. He referred workshop participants to the criteria and mechanisms developed by the United Nations System Standing Committee on Nutrition and the WHO Partnership for Maternal, Newborn, and Child Health (PMNCH). Marks’s suggestions prompted debate about how to cultivate public trust in public–private collaboration
in food and nutrition and whether there were any mechanisms that could be helpful in generating that trust.
Finally, Michael McGinnis offered some closing remarks on general areas in food and nutrition that he considers ripe for future collaboration, based on mutual interest among all sectors. These include research (e.g., developing a common research agenda aimed at understanding variation in basic caloric requirements) and assessment (e.g., pooling data on eating habits and the impact of eating habits on weight and health status). Indeed, that the mutual desire for more data and knowledge makes research and assessment especially conducive areas for public–private collaboration was an overarching theme of the workshop.
One outcome of the Building Trust Initiative was a one-page list of questions to consider when assessing whether to engage in a partnership, that is, the types of things that potential partners should think about as they enter into a dialogue on multisectoral collaboration (Table 4-1). Finegood offered the one-page list of questions as a draft assessment tool for use during the workshop. Participants used the questions as guidance during the second breakout session, when exploring “metrics of acceptability,” or factors to consider in deciding whether to engage in a partnership. The questions were used again during the third breakout session, when participants explored possibilities for partnerships on specific topics.
The draft assessment tool has three general categories, or domains, of questions:
1. Initiation. The first set of questions revolves around what potential partners should be thinking about at the beginning of a partnership. The benefit-risk decision-making pathway displayed in Figure 3-1 from Kraak and colleagues (2011) would fall within this domain. Based on work done during the Building Trust workshops, Finegood listed several questions, or issues, to consider during the initiation phase of a partnership: level of authentic trust; commonality of interests; brand complementarity; appropriate authority and mandate to negotiate; appropriate expertise, capacity, and resources; feasibility of achieving common goals; legal accountability throughout; and risk mitigation.1
1 Most of these issues were addressed during this workshop and are summarized elsewhere in this report. The only one that was not discussed in extensive detail was brand complementarity. According to Finegood, clashing of a private brand and a nonprofit brand and the impact of
TABLE 4-1 Draft Tool for Assessing Partnerships
|Value of Item|
Initiation: Shall I engage in this partnership?
Level of authentic trust
Commonality of interests
Appropriate authority and mandate to negotiate
Appropriate expertise, capacity, and resources
Feasibility of achieving common goals
Legal accountability throughout
Risk mitigation (for media attention, public scrutiny)
Development: If yes, how do we maintain our relationship?
Leadership and champions identified
Clarity of roles, responsibilities, accountabilities, jurisdiction, and commitment to completion
Opportunity for sharing assets (e.g., reach, resources, influence)
Commitment to and capacity for internal and external communications throughout
Capacity for project and issues management
Completion: And now that we have achieved our goals…
Planning for project closure and celebration
Evaluation of partnership is planned and resourced
SOURCE: Diane Finegood and Margaret Rudolf.
2. Development. The second set of questions to consider when assessing partnerships pertains to the maintenance of the partnerships, including whether to disengage from a partnership. Again, based on work conducted during the Building Trust workshops, Finegood listed several questions, or issues, to consider when evaluating this development phase: identification of leaders and champions; clarity of roles, responsibilities, accountabilities, jurisdiction, and commitment to completion; opportunity for sharing assets; commitment to and capacity for internal and external communications; and capacity for project and issues management.
3. Completion. It is just as important to consider termination of the partnership as it is initiation and development. Many Building Trust workshop participants identified two key issues, or questions, to consider when evaluating the completion phase of a partnership: (1) whether
the clash on that partnership had a great deal to do with many Building Trust workshop participants identifying brand complementarity as an important issue.
project closure and completion have been planned and (2) whether evaluation of the partnership has been planned and resourced.
Reflecting on Workshop Participants’ Own Best Practices
During the second breakout session, workshop participants were asked to think about past partnership experiences and to consider two questions. First, what benefits and risks of partnership should I be considering when determining the balance across all partners (e.g., money, in-kind resources, other assets)? Second, how do I determine the acceptability of a specific public–private partnership and whether I want to enter into that partnership? Groups were asked to report back to the group at large any common themes among responses to the second question only. Those report-back
Reflecting on Our Own Best Practices: Report-Back
from the Second Breakout Session
Workshop participants were asked to think about partnership experiences they have already had and to consider how they determine the acceptability of a specific publicâ€“private partnership. Here is a summary of the “metrics of acceptability” identified by the mixed-sector breakout groups. The numbers in parentheses indicate the number of breakout groups (total of six) that identified that particular metric (although not necessarily with the language used here) as being important.
• Agreement on a common agenda and goal, with return of investment for all partners (5). One breakout group spokesperson said, “We want to make sure that there are some common goals or common approaches to what you want to achieve.” Another breakout group emphasized that recognizing potential areas of disagreement and explicitly agreeing that those areas will not be addressed is an integral part of identifying where commonalities reside and, thus, where productive partnerships can be nurtured.
• Contributions of partners, with each partner bringing something unique and complementary to the table and with all partners engaged and committed and not just signing on to the cause (5). With respect to unique contributions, one breakout group spokesperson explained, “That doesn’t necessarily mean a tremendous amount of expertise, although obviously you want that, but it could also mean that they bring something else to the table that’s important, be it political power or something else.” Another breakout group identified the importance of a balanced representation between “the usual players” and new players who bring with them the potential for innovation. Yet another group emphasized the importance of maintaining a balanced bias.
results are summarized in Box 4-1. As previously mentioned, the groups were mixed with respect to sector, with representatives from government, academia, industry, and NGOs present at each table. Thus, the breakout discussions and report-backs to the group at large represent diverse sets of voices.
Finegood observed that the report-back results were very closely aligned with the types of questions and issues that were included in the draft tool (Table 4-1). However, she emphasized the need to modify the language of the draft tool in order to make it more accessible to more potential partners. The breakout groups reported that many representatives from the different sectors identified the same key metrics of acceptability but that different language was sometimes used to articulate those metrics.
• Compatibility, both individual and institutional (3) (e.g., core values of the partners). With respect to individual compatibility, one breakout group spokesperson said, “We have to be able to get along. We don’t want to fight with each other at the table. If we have any issues with that, we might want to reconsider the relationship.”
• Scope and extent of the project (3), including its feasibility and achievability.
• Past partnership history and performance (2) (e.g., proven track record of success, history of credibility).
• Having clear procedural steps in place (2), including an operation plan or research design in place, metrics for measurement and evaluation, and procedural steps for opting out. With respect to evaluation, one breakout group emphasized the importance of a “built-in evaluation throughout the partnership” because a partnership is a “living entity that develops over time.”
• Sense of authentic trust among the sectors that allows for adaptation and (anticipated) progress (2). Also, the manager of the partnership, if there is one, must be trusted by all parties.
• Public trust (1) (i.e., whether the public is going to react negatively to the partnership).
• Apparent importance of solving the problem (1).
• The absence of “nonstarters” (1). One breakout group spokesperson explained, “If there is a subject matter or something that just doesn’t align with the agenda of your organization, you might not want to get into that relationship” (e.g., tobacco and public health).
• Benefits of participation considered against the risks and benefits of nonparticipation (1).
Importantly, decisions about cross-sector partnerships extend beyond whether to enter into a new partnership. As Castle pointed out, sometimes partners need to disengage from collaborations to which they have already committed. Castle remarked that an important feature of the Kraak and colleagues (2011) benefit-risk decision-making tree is that it includes decisions for disengagement alongside decisions for engagement. In voluntary partnerships, Castle said, “opting out as smoothly as you opt in should be a guiding light.” Marks noted that sometimes there are irresolvable ethical issues. He said, “Some kinds of partnership may not be appropriate in certain circumstances. It’s important to keep that in mind.”
Navigating the Ethics of Engagement2
Marks emphasized that from the perspective of the public sector and the academy, it is important to safeguard both integrity—including institutional integrity, individual integrity, and scientific integrity—and public trust. He stressed, “public trust extends beyond the legitimate but narrower concerns about conflicts of interest.” In navigating the ethics of public–private partnerships, Marks said it is important to keep in mind two elements: substantive criteria and procedural mechanisms, including some form of initial review, monitoring and evaluation, and ex post analysis. A discussion of ethics requires recognition that there are some cases where one should not engage in a public–private partnership and other cases where one should disengage, as raised in the previous section. Elaborating on this, Marks observed that some private institutions may not be appropriate partners, that some initiatives may not be suitable for public–private partnerships, and that some kinds of partnership may be inappropriate.
Marks suggested that workshop participants look to the substantive criteria and procedural mechanisms developed by the UNSCN and the WHO Partnership for Maternal, Newborn, and Child Health as models for navigating the ethics of public–private partnership engagement. Both entities have wrestled with conflicts of interest and the institutional and scientific integrity and public trust challenges created by private sector engagement in public sector efforts. Marks noted that he offered these examples as starting points for discussion.
The UNSCN produced a private-sector engagement policy in 2006 and a follow-up proposal in 2007 (UNSCN, 2006, 2007). Both documents contain a series of “principles of engagement”:
2 This section summarizes Jonathan Marks’s presentation.
• relevance to UNSCN’s vision and mandate;
• effectiveness and efficiency of the partnership as it relates to UNSCN goals (i.e., the outcomes of the partnership should be aligned with achieving UNSCN goals, and the use of UNSCN’s resources should be appropriate when compared to alternative actions);
• management of conflicts of interest, including identifying the interests of partners, assessing potential conflicts of interest, and recognizing in some cases that exclusion is the appropriate response;
• independence from vested interests based on credibility concerns;
• diversity, such that no one type of private sector organization receives preferential treatment;
• differential safeguards, meaning the safeguarding of activities related to public policy making from corporate influence; and
• the promotion of and respect for human rights principles.
Both documents also differentiate among three types of engagement: (1) direct funding; (2) contributions in kind, including access to resources; and (3) dialogue.3 Marks noted that the policy effectively takes financial and in-kind contributions “off the table.” He quoted Rule 20 of the UNSCN 2007 document: “In order to protect against institutional conflict of interest, the Steering Committee will ensure that the SCN does not accept financial or in-kind contributions from food-related PSOs (private-sector organizations) for any of its activities, whether they are developed through Working Groups or through the Steering Committee/Secretariat based work plans.” With respect to other, non–food-related PSOs, the policy states in Rule 22 that direct funds and in-kind contributions can only come from PSOs with “satisfactory assessment ratings with regard to their performance on human rights, labour rights, environment and good governance criteria” (UNSCN, 2007).
The WHO PMNCH has made two attempts to develop a set of principles for private-sector engagement. The first attempt resulted in a set of five principles (based on the WHO Policy Framework for Engaging and Working with the Commercial Private Sector):
1. The interaction must demonstrate a clear added value for public health.
2. WHO must maintain its independence, in keeping with WHO policy on conflicts of interest. (Marks noted this requires more broadly
3 Although not of relevance to the UNSCN, these documents also identify joint delivery projects as a fourth potential type of engagement.
maintaining objectivity and the three “I’s”: integrity, independence, and impartiality.)
3. The interaction should not be seen as an endorsement of a particular product or activity, nor should any private-sector entities be excluded at the benefit of others.
4. Cooperation with the private sector should be transparent.
5. WHO should not collaborate with companies who produce a product or engage in practices that will be detrimental to health or harm its reputation (WHO PMNCH, 2010).
More recently, Marks said, the PMNCH appears to have expanded and subtly modified this set of principles, such that there are now seven principles of private-sector engagement:
1. strategic alignment;
2. clear added value;
3. independence and impartiality;
4. no exclusivity;
6. no conflicts of interest; and
7. process, with an emphasis on due diligence.
With respect to the seventh principle, the PMNCH calls for both risk assessment and risk management. Criteria for partner selection include a corporate track record of social responsibility and leadership, a history of commitment to development and health goals, a responsible environmental and labor practice, and a positive public image. Addressing the implications of these approaches for public–private partnerships related to food and nutrition, Marks said, “I do think that some kind of due diligence on the private sector partners will be vital when it comes to addressing public trust.”
Marks also stressed the importance of conducting what he called a “3-P impact assessment,” that is, an examination of the partnership before, during, and after the partnership has ended. Like an environmental impact assessment or a regulatory impact assessment, he said, “it’s really important to have that kind of assessment process.” Such assessments can help to identify gaps in the mission of the public partner left by even legitimate public–private partnerships, that is, ones that fulfill all substantive criteria and have all of the necessary procedural safeguards in place. Sometimes partnerships are so narrowly focused that they ignore other key objectives to which a public-sector entity is committed by statute or by virtue of its mission statement. Where there are legitimate concerns about failure to satisfy its mission, Marks suggested a necessary precondition for a public-sector actor entering into a public–private partnership on one initiative
might be that it would, at the same time, make a commitment to address another initiative that would otherwise be neglected.
Finally, Marks encouraged cultivation of what he called a “moral imagination.” Very rarely do ethical dilemmas have only two possibilities. Usually, there are at least half a dozen solutions to any problem, with one or two being terrible and the challenge being to identify the optimal solution among the others. He said, “As we face really complex social problems in relation to food and nutrition, it’s important to exercise and cultivate that moral imagination.” As an example of the type of problem requiring what Marks called “moral imagination,” he pointed to the pre-workshop survey data indicating concern among industry representatives that industry-funded research is not widely respected. He suggested reconsidering options that have been proposed in the past but set aside, such as capitation fees on industry-sponsored research or other mechanisms to generate funds for research that might not be in the direct interest of industry but would serve to create a rich body of food and nutrition research.
Cultivating Public Trust in the Food Industry
Marks’s comments triggered a lively discussion on the broader issue of public mistrust and the food industry, including whether mistrust of the food industry is the same as or greater than mistrust of the pharmaceutical industry. One participant viewed the two industries as equally problematic in the public eye and argued that because the pharmaceutical industry is able to engage in successful public–private partnership, the food industry should be able to do the same. The barriers should not be perceived as insurmountable. Yet, not everyone agreed. Another workshop participant said that on the contrary, people trust the food industry less than they trust the pharmaceutical industry. The question is, Why? Are there mechanisms used by the pharmaceutical industry that could be applied to help build public trust in the food industry?
It was suggested that perhaps the problem is with the public understanding, or misunderstanding, of risk and how the public thinks about risk in the context of food. In other words, pharmaceutical products come with risk, and the public is aware of that risk and accepts it because the potential benefits are so great. Public perception of food products, on the other hand, is that such products carry no risk at all and that the food industry is to be blamed for problems that arise. Castle identified two critical differences between the two industries, both of which make the pharmaceutical industry more predictable as an industry partner and, therefore, more trustworthy. First, the pharmaceutical industry tends to be more vertically integrated than the food industry, with the entire value chain controllable. Second, intellectual property management in the pharmaceutical industry is struc-
tured primarily around patents, whereas in the food industry it is structured primarily around trade secrets. Neither structure is “better,” Castle said, but there is predictability with the timeliness of public disclosure of patenting that does not exist with trade secrets. The greater predictability helps with managing uncertainties. Marks suggested that an important difference between the two industries is the higher quality of evidence of benefit versus risk required for pharmaceuticals. He referred workshop participants to a recent IOM (2010a) report Evaluation of Biomarkers and Surrogate Endpoints in Chronic Disease and its call for “the same level of scientific evidence of benefit and risk” for food as for drugs.
During the third breakout session, workshop participants chose three topics in food and nutrition that could serve as good subjects for public–private collaboration: (1) obesity, specifically why the challenge of developing a public–private collaboration focused on obesity is different from other food and nutrition–related public health challenges; (2) food labeling and messaging; and (3) calorie reduction. Three breakout groups were formed, with workshop participants joining whichever group they wanted to join. The groups were asked to articulate a goal for a partnership on their topic and, using the draft assessment tool as a guide, to identify questions they should be asking about a potential partnership at this very early stage of the conversation. As with the second session, each breakout group included representatives from all sectors (i.e., government, academia, private industry, NGOs), and thus each report-back to the group at large reflects a collection of diverse voices.
Obesity was mentioned several times during the course of the workshop as an example of the type of complex public health challenge requiring an “all-sails-up” approach. For example, Dietz commented on how the challenge of obesity is different from other public health challenges, such as increasing fruit and vegetable intake, because obesity itself is such a broad target. Its broad scope makes it difficult for partners to agree on a common agenda and achievable goal. Narrowing the target could alleviate some of that difficulty. As Finegood pointed out, narrowing the target sometimes also increases public acceptability of a partnership. Thus, the breakout group spent most of its time trying to narrow the target and identifying specific obesity-related issues that could be addressed through public–private collaboration.
Topics considered by the group included promotion of the desirability of healthy choices; better collection of data on marketing to children; and the promotion of fruits, vegetables, and grains. The one topic that received more attention than the others was the development of food technologies that promote healthy weight, for example, products with fewer calories per weight or volume. Several group members observed that focusing more narrowly on pro–healthy weight technologies would be less contentious than focusing more broadly on reducing overall calorie consumption. Many group members also raised the promotion of physical activity as another possible target for a public–private collaboration aimed at reducing obesity. As with pro–healthy weight technologies, focusing more narrowly on physical activity would be less contentious than focusing more broadly on reducing overall calorie consumption. As they said, “Nobody has to give up profit in order to promote physical activity.” A few participants in the group, however, cautioned that some public-interest NGOs and academics view this as a diversion of attention by the food industry from the products they manufacture and market to physical activity solutions, leading to stakeholder mistrust in the industry’s motives unless complementary activities (e.g., product reformulation, pledges and commitments to improve marketing practices) are also undertaken.
While the group did not explicitly pull from the draft assessment tool any metrics of acceptability, much of the discussion was centered on risk mitigation, with pro–healthy weight food technologies and the promotion of physical activity considered less threatening than other goals. The discussion of physical activity as a target led to some dialogue about whether there were any partners that would not be welcome at the table because of the risk of public mistrust. For example, would such a partnership exclude sugar-sweetened beverage companies? Some participants in the group expressed concern that excluding potential partners would actually increase the risk of mistrust. Finegood said that one of her take-home lessons from that particular breakout discussion was the notion of “safety in numbers,” that is, the more partners at the table the more likely is the partnership to be acceptable to the public.
Food Labeling and Messaging
The food labeling and messaging breakout group spent a great deal of time searching for common ground, that is, an area where all sectors could contribute and would benefit. One participant said, “We spent more than half our time just trying to get to what we were going to address.” The conversation progressed only to the point of identifying a common goal to develop a process for the qualification of biomarkers that can be useful in promoting healthy foods (e.g., biomarkers that clinicians could use as
predictors of health outcomes). To encourage wide participation, the focus of the initiative would be on the qualification process itself, not on any particular type of biomarker.
While the breakout group did not explicitly identify “risk mitigation” from the draft assessment tool as a key factor to consider when evaluating whether to enter into a public–private partnership aimed at developing a biomarker qualification process, it did address risk. Specifically, the group discussed the risk associated with not considering the legal issues that would have to be taken into account to ensure that this type of initiative, and the qualified biomarkers resulting from it, would actually be applicable in the market (i.e., that there would be no postmarket issues around how claims substantiated by the qualification process are being communicated). Likewise, while the group did not explicitly pick “commonality of interests” from the draft assessment tool as a key metric of acceptability, clearly it was an important focus of the conversation.
The calorie reduction breakout group progressed the furthest in terms of identifying a goal for a public–private partnership around a specific issue and identifying key metrics of acceptability from the assessment tool. Many group members supported a focus of their hypothetical partnership on a behavioral research project on calorie reduction. These members identified two specific goals: (1) gauge people’s awareness of “know your number,” possibly using EPODE as a model, and (2) conduct a natural experiment on the impact of front-of-package calorie labeling, using the introduction of front-of-package labeling as a baseline and conducting multicenter clinical trials to evaluate the impact of reduced-calorie products in different communities.
From the draft assessment tool, many group members identified “level of authentic trust,” “commonality of interests,” and “risk mitigation” as key factors to consider when thinking about whether to engage in a behavioral research partnership; “clarity of roles, responsibilities, and accountabilities” as an important factor to consider when evaluating development of the partnership; and “evaluation,” not just of the research but also of the partnership itself, as a key factor to consider when assessing whether the partnership has reached its goal(s).
Reflections on Applying the Draft Assessment Tool to Possible Partnership Projects
Most participants reflected that discussing cross-sectoral collaboration in the context of concrete issues, such as those addressed during the
third breakout session (i.e., obesity, labeling and messaging, calorie reduction), is much more challenging than discussing collaboration in general terms. Finegood received a mixed response when she asked workshop participants how helpful the third breakout session had been compared to the first two. The mixed response led to some discussion about what, if anything, could have been done differently to push the breakout sessions further along in their conversations and what could be done next to push the next conversation(s) further along. For example, did the calorie reduction breakout group progress the furthest because, by chance, the “right group” of people had assembled? Would the other two breakout groups have progressed further if the groups had been assembled more selectively? Did NCI-USDA take the better approach in their meeting, by assembling the “right group” of people (i.e., research scientists) to identify topics for partnership—in that case, scientific research gaps—before discussing how those gaps could be filled through public–private collaboration? A participant who attended the NCI-USDA meeting said, “I think you can do it either way, but the bottom line is, as you move forward, you will always be going back and forth.” That is, even as a conversation moves forward into the specifics of a particular public–private partnership, at various times participants will have to revisit the basic premises of the partnership. It was suggested that having facilitators present in each group might have helped keep the groups on task. However, some people expressed concern that a facilitator might have been too restrictive at such an early point in the conversation and that one of the goals of the workshop was to “openly explore” opportunities for partnership.
While there are many successful public–private partnerships to celebrate and many benefits to be gained by entering into such partnerships, risk and risk mitigation are clearly front and center in many people’s minds when thinking about public–private collaboration. McGinnis observed that all of the suggested topics, or projects, articulated during the third breakout session report-backs were ones that could be engaged without a great deal of threat to individual participants.
In his closing remarks, McGinnis identified three types, or “three buckets,” of reduced-risk activities. First are those that focus on what he called the “antecedents” to regulatory activities and product development. Most partners are unlikely to get involved in the regulatory process itself or in the actual development of products that are going to be marketed, but the antecedents to those events, he said, “can be ripe for collaborative work.” His comments echoed earlier remarks by Woteki, who pointed out the potentially very important role of collaborative work in the pre-competitive
research arena. The second bucket of potential collaborative activity is filled with activities that work “in parallel” to the marketing of products. Again, it is unlikely that individual companies are going to collaborate in marketing their products, but a number of parallel activities, such as social marketing or the sharing of information about the relationship between marketing and behavior, could be undertaken collaboratively. The third bucket is filled with “results,” or evaluation, of previous activities. For example, what is it about particular regulatory, research, or marketing processes that leads to certain results? He said, “All three of those areas have many opportunities for unthreatening, if you will, collaborative work.”
Additionally, as mentioned earlier, McGinnis identified four common interests among the different sectors that not only are appropriate for, but necessitate, collaborative action: (1) assessment (e.g., pooling data on eating habits and the impact of eating habits on weight and health status); (2) research (e.g., developing a common research agenda aimed at understanding variation in basic caloric requirements); (3) marketing (e.g., synergizing social marketing strategies aimed at improving healthy eating); and (4) vision (e.g., working together to develop a vision of what is possible). In McGinnis’s opinion, it is our “our obligation” to start with the assumption that action in any of these four areas “has to be collaborative” and to undertake these activities at the individual level only if collaborative efforts fail. He urged, “Our starting point should be that any activity in these arenas ought to be a collaborative effort.” With respect to tangible next steps, he suggested that Food Forum members consider establishing working groups to propose and assess possible collaborative projects, including possible participants, and the appropriate neutral venue or body to convene and coordinate them.