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Do the solutions for global health lie in healthcare?

BMJ 2014; 349 doi: (Published 25 September 2014) Cite this as: BMJ 2014;349:g5457

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Conflicts of interest and global health and nutrition governance - The illusion of robust principles

In the run-up to the Second International Conference on Nutrition (ICN2), Jonathan Marks warned against downplaying the fundamental differences between the commercial interests of multinational food companies and those of public sector agencies. If public health officials do not acknowledge the divergent interests, he suggested, they risk harming their public health mission, institutional integrity and ultimately public trust.

Yet, the current discourse ignores the problem of involving food TNCs in public decision-making processes, acceptance of funds and resources in the name of partnership or stakeholder engagement. The trend to increase such engagement reduces and almost eliminates public policy spaces without corporations. Questioning of close relationships is frequently answered with reference to policies claimed to ‘mitigate’ the risks of such relationships.

For example, the ICN2 Framework for Action, which guides the implementation of the ICN2 Rome Declaration, urges governments to “strengthen and establish, as appropriate… multi-stakeholder mechanisms for food security and nutrition to oversee implementation of policies, strategies, programmes and other investments in nutrition” to create an “enabling environment for effective action.” While asserting that “such platforms may be needed at all levels” it refers to “robust safeguards against abuse and conflicts of interest.” (1)

The catch is that robust, comprehensive conflict of interest safeguards do not exist with respect to global food and nutrition governance. This lack became clear in the debates on the formulation of WHO’s Framework of engagement with non-State actors in January this year. (2)

Does the conflict of interest exercise of the Scaling Up Nutrition (SUN) initiative, initially introduced as a PPPPP - a “principled, people-public-private partnership” – at the World Economic Forum, fill this gap? Next week will see the celebration of SUN’s completed two-year project on conflicts of interest. This Gates Foundation-funded project designed “living documents on conflicts of interest,” presented as assisting governments in ‘SUN countries’ to prevent and manage conflicts of interest while the national nutrition arena is reshaped along SUN’s multi-stakeholder Engagement Principles.

At first glance, SUN’s definitions and interpretation of institutional conflict of interest seem congruent with those adopted by the U.S. Institute of Medicine:

"Institutional conflicts of interest arise when an institution's own financial [i.e. secondary] interest or those of its senior officials pose risks to the integrity of the institution's primary interests and missions." (3)

According to the project’s centrepiece Reference Note (4):

“An individual conflict of interest arises when the pursuit of the private or secondary interest of an individual has the effect of compromising, interfering with, or taking precedence of the joint endeavour.” (Para. 14)

An organizational or institutional conflict arises when the pursuit of an organization’s interest, whether ‘private’ or secondary, has the effect of compromising, interfering with, or taking precedence of the joint endeavour.” (Para.15)

Closer reading reveals profound differences with the IoM definition. The mandate of nutrition initiatives, i.e. the protection, promotion and respect of the right to adequate food and nutrition, is not taken as the ‘primary’ interest in either definition but the “joint endeavour”.

The primary purpose of SUN’s CoI exercise seems to be the protection of “establishing synergies between organizations …” by turning “stakeholders’ interest into converging interest.” (Para 10 & 19) As the Reference Note explains, the focus is on “inter-organizational conflicts…. that might arise in SUN countries and cannot easily be resolved through negotiation.” (Para 8).

The Reference Note, as well as the project’s Enhanced Learning Exercise, blurs crucial distinctions amongst:
• clashes or diverging opinions between actors; and
• the fundamentally differing fiduciary duties/mandates (primary interests) of market-led and public interest actors;
• “conflicts of interest” which relate to conflicting interests within a person or an institution; (5)

All appear in the Reference Note as ‘conflicts of interest.’ This blurred terminology hinders SUN participants’ understanding of the ultimate aim of conflict of interest policies: i.e. the protection of integrity, independence and public trust in persons and institutions serving public interests.

It obscures the fact that conflicts of interest are an important legal concept. Establishing conflict of interest policies are an integral part of UN agencies’ duty to establish the Rule of Law. According to the 2006 OECD Guidelines on Managing Conflict of Interest in the Public Service, public institutions should:
• ensure that effective procedures are deployed for the identification, disclosure, management, and promotion of the appropriate resolution of conflict-of-interest situations (comprehensive conflict of interest policies address CoIs, e.g. in public procurement, the revolving door problem, and the need for whistle-blower protection);
• support transparency and scrutiny; and
• create an organisational culture in which dealing with conflict-or-interest matters can be freely discussed and raised.

This does not seem to have been the focus of SUN’s CoI exercise. Its' Reference Note deters questions as to whether businesses should be invited as ‘stakeholders’ in public nutrition activities and empowered to shape nutrition agendas. Its basic assumptions are “good governance is inclusive” and actors in the nutrition arena should build “trust to permit such inclusiveness” (Para 9; cf. also Para 22.2.). There is no challenge as to whether the spirit of conflict of interest regulation is upheld when public interests are ‘aligned’ with those of corporate participants or TNCs are positioned in SUN’s Lead Group.

Critics who believe that those working in the nutrition arena should keep at arm’s length distance from food and beverage corporations and who advocate regulation of harmful marketing practices through legislation and naming-and-shaming are often ignored. The latest SUN Evaluation Report refers to persons with “phobias” and “hostile feelings” towards industry, who may “potentially sabotage the prospects of multi-stakeholder efforts to scale up nutrition.” (6)

Instead of sidelining and discrediting such voices, the SUN Secretariat may consider the integrity of their case and terminate the “Learning” exercise before SUN’s dilution of the meaning of conflict of interest contaminates the global nutrition arena. Otherwise, SUN’s exercise may cast doubt on governments’ and public interest actors’ understandings of CoI issues and cause a harmful redefinition of conflict of interest policies in the countries where SUN operates.

(1) FAO/WHO (2014). Second International Conference on Nutrition
Rome, 19-21 November 2014, Conference Outcome Document: Framework for Action, Doc. ICN2 2014/3 Corr.1; October 2014. Rome & Geneva,
(2) WHO (2015). Study on practices of organizations of the United Nations system relating to conflict of interest in their engagement with the private sector. Geneva, World Health Organization & other relevant documents on
(3) Lo, B. and M. Field, editors. Institute of Medicine (US) Committee on Conflict of Interest in Medical Research, Education and Practice, Eds. (2009). Conflict of interest in medical research, education and practice. Washington DC, National Academics Press.
(4) For more information & Reference Note: Engaging in the SUN Movement: Preventing and Managing Conflicts of Interest, March 2014, cf. &
(5) Cf e.g. Peters, A. & L. Handschin eds. (2012). Conflicts of interest in global, public and corporate governance. Cambridge & New York, Cambridge University Press, p. 5 & 363 for some clarity on distinctions
(6) Mokoro, in cooperation with Valid International & FEC Consulting (2015). "Independent Comprehensive Evaluation of the Scaling Up Nutrition Movement - " FINAL REPORT Main Report and Annexes, 15 January

Competing interests: No competing interests

12 February 2015
Judith Richter
Associate Senior Research Fellow
Institute of Biomedical Ethics and History of Medicine Zurich University Pestalozzistrasse 24 Ch-8032 Zurich