Public-Private Partnerships in Mexico: Implications for Public Health Nutrition Governance
The Problem
Obesity and associated noncommunicable diseases in Mexico
• Obesity was declared a national public health emergency in 2016 and again in 2018.1,2
• More than 250,000 people die each year from causes related to noncommunicable diseases, including heart disease and diabetes.3
• The latest National Health and Nutrition Survey (Spanish acronym ENSANUT) reported that the combined prevalence of overweight and obesity in adults was 75% and the prevalence of previously diagnosed diabetes was 10.3%.4
• According to the ENSANUT, 35.5% of children between 5 and 11 years of age and 38.4% of adolescents 12 to 19 years of age are overweight.4
• Regular consumption of sugary drinks has been estimated in more than 80% of the population, regardless of age. Sugary drinks are the primary source of sugar in the diet and 69% of the added sugar consumed by Mexicans derives from sugar-sweetened beverages.5
• 65% of children ages 5 to 11 and 35.4% of adults reported consuming snacks and desserts every day. Evidence has confirmed how the increase in obesity and related diseases is linked to high consumption of sugary drinks and ultraprocessed foods.6
Transnational food and beverage industry involvement in policymaking
Recent concerted efforts from the current administration (2018 - 2024) to reduce the high burden of obesity and diabetes in Mexico notwithstanding, the involvement of the food and beverage industry in policymaking and in the public debate on food policy has been the norm for many years, without being perceived as a negative or an issue of concern by policymakers, academics, or civil society groups.7-9 Multiple studies have shown the involvement of the food industry in the policy process, how close food industry actors have been to policymakers, and how involved they have been in pushing solutions to prevailing obesity and diabetes trends in the country that protect their own interests.9-12
This influence persists through different means and types of action, and despite changes of leadership in the federal government, the latest in 2018.11 One of many strategies used by transnational food and beverage industries (TF&BI) is to engage in public-private partnerships (PPPs) for policy and programs to improve health, nutrition, and access to water. These reflect an inherent conflict of interest for such industries but have been framed as actions of corporate social responsibility (CSR)13 and are not commonly perceived as a threat to public health efforts.
While more attention has been drawn to the topic of corporate influence in public health policy,10,14,15 the TF&BI continue to exert their power in different ways in public health policy. For instance, they participate in policy dialogues (e.g., the 2019 consultation on front-of-package labelling), lobby policymakers to delay adoption and implementation of policies, and partner with them to implement policies.16,17
Public-private partnerships as a corporate political activity
Trends in noncommunicable diseases are a serious global concern. One strategy encouraged at the international level to prevent and control them is to promote PPPs. Likewise, engaging in PPPs is a form of corporate political activism that tobacco, alcohol, and ultra-processed food corporations have embraced in the past.18 Evidence suggests that PPPs are often ineffective in improving public health and are often used as a corporate strategy to interfere with public health policy. The primary risk of these partnerships is the influence corporations can wield to neutralize government efforts to improve health policies that go against their favour; and in lobbying for soft policies to continue these partnerships that favour their branding.19 In today’s global food governance, private actors, in particular TF&BI, play a larger role than ever before.20,21
This study confirms that in Mexico this type of PPP has produced minimal gains for public health while boosting the credibility of the corporate partners, in this case the TF&BI. Engaging in PPPs with food industry actors should be carefully assessed, in particular if such partnerships lack clear governance principles and safeguards for transparency and public accountability.
Methods
We conducted a qualitative study to explore four PPPs* aiming to control obesity, increase physical activity levels, and improve access to drinking water and sanitation in Mexico. These PPPs were established during the last administration (2012-2018), which also launched the National Strategy for the Prevention and Control of Overweight, Obesity, and Diabetes in 2013. These PPPs likely had at least 15,000 beneficiaries per program and multiple implementation sites.
a) “Hydration Centres” [Centros de Hidratación] sponsored nationally by Coca-Cola with the Ministry of Education and the Ministry of Health
b) “Water, Sanitation, and Hygiene” [Agua, Saneamiento y Salud], a nationwide project promoted by Pepsi-Co, the Inter-American Development Bank, and the National Water Commission
c) “Reach 100” [Ponte al 100], an initiative launched by Coca-Cola with the Ministry of Health and the National Commission for Physical Culture and Sports (CONADE)
d) “Nestlé for Healthier Kids” [Nestlé por niños saludables/Nutrir], a project promoted by Nestlé, the Ministry of Education and Ministry of Health.
We conducted 26 interviews with industry and government officials, program implementers, and experts in the field between March and June 2020. We collected and reviewed 199 documents related to the selected PPPs and the Mexican context during their operation, including public and private reports and freedom of information (FOI) requests. We analysed the information thematically using a combination of theories and frameworks related to good governance principles in health policy and the programmatic and operational aspects of health programs to guide our results.22
*Some PPPs were existing continuations of past programs, and some PPPs were still ongoing when this study ended.
Summary Of Findings
We identified three main types of PPP arrangements between the public and private sectors:
1) The private sector joins a public action, but only for a specific part or implementation phase of the program (also framed as donations).
2) The private sector presents a project on its own terms. The public partner has little influence on its design but has freedom of action (for implementation).
3) The private sector is the main designer, implementer, and decision-maker. The government becomes an instrument to achieve corporate/private objectives.
In summary, our findings indicate that:
• All the PPPs examined had minimal available public information on their duration, evaluation, impact, and governance.
• Governance around the PPPs studied was weak. No clear principles were followed consistently nor transversally among partners, including those of accountability, transparency, fairness, participation, integrity, and credibility, among others.
• The federal government relied on private sector aid to accomplish public health aims (e.g., provide a service, such as drinking water fountains).
• Some actors interviewed perceived TF&BI support as an important source of economic aid to the government.
• Other actors interviewed perceived TF&BI support as a threat to the public health agenda or saw PPPs as a mechanism that is diluting public health impacts and serving commercial ends instead.
• Several interviewees framed the obesity problem and the solution to it around changing individual behaviours, shedding light on how ingrained this narrative is among public and private actors, although primarily employed and propagated by the food industry and its allies.
Problems Identified and Potential Solutions
We identified several problems in the four PPPs studied. They range from programmatic issues such as implementation, monitoring, and evaluation of the programs designed and implemented through these PPPs to the governance principles followed, including issues of transparency and accountability. We propose some potential solutions based on our findings and our literature review.
Problems
Related to design, implementation, and evaluation issues
• We found several weaknesses and problems of execution in all the PPPs studied, such as i) uncoordinated efforts and arbitrary decisions made at the local level (by a school, its principal, or an authority at the municipal level); ii) lack of follow up of the first intervention with the population; iii) unclear information between the population targeted in implementation versus populations reached afterwards.
• Some third-party evaluations of the PPPs were available to the public. Still, in general, tools or resources on the indicators used to monitor and evaluate program outcomes and impact were not available.
Related to transparency and accountability
• Private institutions had their own operating methodologies and records; however, these were not available to the public.
• The public partners did not have complete and accurate information on the programs conducted under PPPs. The information available (through FOI requests) is limited.
• The PPPs studied produced benefits for the private entities involved and alleviated the net financial burden of public programs but did not have any tools or resources available to ensure transparency and accountability.
• The PPPs studied failed to show a positive effect on water drinking habits, changes in food consumption, physical activity levels, or access to water or have a measurable impact on obesity.
Related to other good governance principles
• Inconsistencies and violations of principles related to ethics, inclusion, justice, and anticorruption efforts, as well as the principles of good governance, were identified in publicly available documents.
• Although PPP arrangements called for beneficiaries to be actively involved in the programs, there was little or no evidence that the beneficiaries participated continuously or in a meaningful way in decisionmaking or program operation.
• Although some PPPs were subject to greater scrutiny by civil society, other PPPs were not and continued to operate without clear accountability mechanisms and with little information available to the public (e.g., the program Nestlé por niños saludables at the local level).
• Promotion of the participating private entity’s brand occurred directly or indirectly, without being perceived as a negative practice by most implementers or beneficiaries.
Potential
solutions
Related to design, implementation, and evaluation of programs conducted under PPPs
• Avoid developing or engaging with national or transnational food and beverage industries, particularly for PPPs related to food, nutrition or water access.
• Apply specific legal resources to ensure effective implementation, monitoring, and completion of the programs currently operating under PPP arrangements.
• Conduct third-party evaluations of existing programs implemented under PPPs.
• PPPs under consideration or already in existence should:
Be reviewed by an independent commission for an initial risk assessment and a due diligence audit of the private partner.
Have clearly defined priorities and attainable goals to benefit the public, with an established, relevant baseline for each PPP to monitor progress.
Include independent actors in the PPP governance structure to monitor and evaluate their implementation and health-related impacts.
Improve availability of reliable, relevant, and timely information to assess PPPs’ true costs and benefits, as well as the programs conducted under such partnerships.
Related to transparency and accountability
• Public entities should seek alternative financing solutions for programs and projects related to food, nutrition and water access, and should ensure financial transparency to avoid engaging with national or transnational food and beverage industries to pursue those aims.
• Existing PPPs or those under consideration, specifically:
They should ensure fiscal transparency.
All actors engaging in a PPP program should be held accountable to the public they purport to serve, and there should be no conflict of interest (in relation to mission, vision, products, practices, and policies) between the private partner and the public entity.
Both entities (public and private partners) should make all information on the PPP publicly available. They both should be held to account, ideally by a third party: beneficiaries and the general population.
Related to governance issues
• Human rights and public interest should be at the centre of public programs related to food and nutrition. Programs should avoid prioritizing the fiduciary duty of any private entity over the right to adequate food and nutrition aims.
• Involvement of beneficiaries is critical to improving the accountability of public and private partners and the credibility and real impact of their programs.
• Action-based and discourse-based principles should match. Principles should have specific indicators, actions and measures to verify compliance.
• Develop clear mechanisms to prohibit the promotion of unhealthy foods and beverages in existing PPPs, and to protect public health aims from any other commercial practices that might result from these engagements.
Recommendations
Based on our research and literature review, we provide several recommendations for each of the actors involved in PPPs in order to serve the public good.
Actions for Government
• Improve resources, access, and tools to enhance accountability in public programs aiming to improve health.
• Public entities should explore alternative schemes of financing for public health programs aiming to control obesity, increase physical activity, and improve access to water and sanitation and other health-related programs, rather than engaging in PPPs with corporations with conflicted interests.
• Government actors in general, and parliamentary commissions (e.g., health, education, and human rights) in particular, should discuss and propose guidelines and legislation to regulate PPPs. These should include restrictions on engaging in PPPs with TF&BI when conducting public programs aiming to control obesity, improve nutrition, increase physical activity levels, and improve access to water and sanitation.
• An expert panel or commission should be formed to evaluate conflicts of interest around potential PPPs and rule for or against the creation of such partnerships, after assessing their risks.
• With regard to existing PPPs with the food and beverage industry, a core redesign should be considered to avoid ineffective interventions supposedly aimed at alleviating public health nutrition problems. For instance:
Develop tools to protect public policy and public programs from partnerships with private sector entities with inherent conflicts of interest.
Ensure the participation of community and civil society groups that support the human right to adequate and nutritious food, including the right to water, as a key element of any intervention used to improve nutrition and health and to address obesity and chronic diet-related diseases.
Enable external (non-conflicted) evaluators to assess the design, implementation, and evaluation of the programs conducted under PPP arrangements.
• In general, improve national norms and regulations on fiscal transparency and on non-promotional practices when engaging in PPPs.
Actions for civil society
• Support citizens and beneficiaries to hold private and public partners to account when they engage in public health programs.
• Question the framing of public problems and solutions when private partners involved, such as national or TF&BI, have conflicts of interest.
• Advocate for community and civil society participation in policymaking and in all stages of developing programs to support the human right to adequate food, nutrition, and water.
• Demand transparency in programs conducted under PPPs and expose potential financing and implementation loopholes that perpetuate the government’s use of such partnerships.
• Analyse discursive commitments (on paper) versus actions taken in existing PPPs to hold them to account.
• Ensure that the human rights to adequate food and nutrition are protected from any commercial interest when engaging with private partners.
Actions for academia
• Conduct and disseminate exploratory studies to generate evidence on PPPs related to food, nutrition, and health at the national and sub-national levels.
• Question the framing of problems and solutions when national or TF&BI are involved in programs or projects related to food, nutrition, and health.
• Independently evaluate the design, implementation, and evaluation of programs conducted under PPPs.
• Academic institutions should follow codes of ethics and guidelines to protect science from any engagement with private partners that may interfere with the performance or impact of research principles.23