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Journal ArticleDOI

Sitting on the FENSA: WHO engagement with industry.

30 Jul 2016-The Lancet (Elsevier)-Vol. 388, Iss: 10043, pp 446-447

TL;DR: When decisions are made that will impact on people’s health, who should be represented at the policy-making table?
Abstract: 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 (the State), or should other stakeholders participate – and if so, to what purpose? To advise? Make decisions? Or as funders? These issues lie at the core of a governance debate1 that has been rancorously discussed in relation to WHO for several years. In May 2016 the World Health Assembly (WHA) reached consensus: “WHO engages with non-State actors ....to encourage [them] to...protect and promote public health” – and considered non-State actors as “nongovernmental organizations [NGOs], private sector entities, philanthropic foundations and academic institutions”2.
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Sitting on the FENSA: WHO
engagement with industry
Kent Buse, PhD and Sarah Hawkes, PhD
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 (the State), or should other stakeholders participate and if so, to what
purpose? To advise? Make decisions? Or as funders? These issues lie at the core of a
governance debate
1
that has been rancorously discussed in relation to WHO for several
years. In May 2016 the World Health Assembly (WHA) reached consensus: “WHO engages
with non-State actors ….to encourage [them] to…protect and promote public health” and
considered non-State actors as “nongovernmental organizations [NGOs], private sector
entities, philanthropic foundations and academic institutions”
2
.
The resolution known as FENSA (Framework of engagement with non-State actors) had a
long and difficult gestation, but is seen by many as a critical element of the ongoing WHO
reform. Members States were generally supportive of the Framework, but NGOs voiced
concern that “FENSA will increase….problematic entanglements between WHO and
powerful private sector actors”, and were disappointed that the Framework fails to
“acknowledge the different nature and thus different roles public and private sector
actors should play in global health governance”
3
. In 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 (NSA), particularly those whose mandate hinges

foremost upon the pursuit of profit rather than public health. WHO has acted upon these
concerns in the past, and has not, for example, engaged with the tobacco or arms
industries. The existence of conflicts of interest policies in WHO have not prevented
problems arising. A Reuters investigation, for example, found not only that regional office
PAHO had accepted money from companies such as Coca-Cola, Nestle and Unilever, but also
that at least two of the 15 members of WHO’s Nutrition Guidance Expert Advisory Group
had direct 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.
Philanthropic foundations can also have an influence and potential conflicts of interest. For
example, the charitable UN Foundation placed a staff member in the WHO Director
General’s office for a 2-year period; and the Gates Foundation seconded a manager to the
WHO Polio and Emergencies Cluster
6
.
The FENSA resolution recognizes and elevates the issue of the potential conflict of risk
(including undue influence in setting/applying policies/norms/standards) from engagement
with NSA and proposes mechanisms to avoid and manage these risks in the interests of
public health including through transparency, enhanced procedures and staff training.
Moreover, the resolution sets out specific guidelines in relation to engagement with each
category of NSA.
FENSA is a necessary but insufficient response to the significant part the private sector plays
determining population level health outcomes. FENSA specifically namechecks the biggest
threat to human health (noncommunicable diseases, which are now the world’s leading
cause of disability and death), but does not go so far as to 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, air pollution, have been
extensively described
7
. 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 brand
WHO, even if well implemented, will not necessarily translate into better behaved industries

at global and national levels that will act to protect and promote 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. Do we rely
upon self-regulation by industry (e.g., marketing codes or voluntary initiatives to reduce
harmful exposure), co-regulation of the activities of industry (e.g. public sector partnerships
with the private sector are an overarching approach within of WHO’s 2013-2020 Global
Action Plan on NCDs
8
), or public regulation of private sector activities. The latter approach is
frequently promoted by experts 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.”
9
Nonetheless, governance scholars note that
problems of enforcement and industry subversion
10
of public health goals raising the
question of the effectiveness of this model.
WHO and its governing body have taken an important step in democratizing 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 aggressively supporting governments and their partners
to govern the health impact of Big Industry. This will entail a shift from treating this as a
technocratic and managerial project to the political one that it patently is. A small but not
insignificant part of the project entails embracing the public interest NGOs, which it has too
long treated as adversaries, as the partners it needs to generate both public support and
political incentives to induce national leaders to act.
1
Bexell M, Tallberg J, Uhlin A. Democracy in Global Governance: The Promises and Pitfalls of
Transnational Actors. Global Governance 2010;16:81-101.

2
World Health Organization. Framework of engagement with non-State actors. Sixty-ninth
World Health Assembly, Agenda Item 11.3. Available at:
http://apps.who.int/gb/ebwha/pdf_files/WHA69/A69_ACONF11-en.pdf
Accessed 30/06/16
3
Lhotská L, Gupta A. Whose health? The crucial negotiations over the World Health
Organization’s future. Available at: http://www.policyforum.net/whose-health/
Accessed 29/06/16
4
Statement from International Federation of Pharmaceutical Manufacturers Associations,
May 2016. Available at: http://www.ifpma.org/wp-content/uploads/2016/05/IFPMA-
Statement-11.3-NSA-May-2016-final.pdf Accessed 29/06/16
5
Wilson D, Kerlin A (2012). Special Report: Food, beverage industry pays for seat at health-
policy table. Reuters, 19 October 2012. http://www.reuters.com/article/2012/10/19/us-
obesity-who-industry-idUSBRE89I0K620121019 [Accessed 30/06/2016].
6
Third World Network, December 2015. WHO: Unease over seconded philanthropic
foundation staff to top management. Available at
http://www.twn.my/title2/health.info/2015/hi151202.htm
Accessed 29/06/16
7
Stuckler D, Nestle M. Big Food, Food Systems, and Global Health. PLOS Medicine, 2012.
http://dx.doi.org/10.1371/journal.pmed.1001242
8
World Health Organization. Global Action Plan for the prevention and control of NCDs,
201W3-2020. World Health Organization, 2013.
9
Faculty of Public Health, United Kingdom. FPH withdraws from responsibility deals.
Available at: http://www.fph.org.uk/fph_withdraws_from_responsibility_deals . Accessed
29/06/2016
10
Abbott, K. and Snidal, D. Taking Responsive Regulation Transnational: Strategies for
International Organizations. Regulation and Governance, 2013;7:96.
Citations
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Journal ArticleDOI
Kent Buse1, Sonja Tanaka, Sarah Hawkes2Institutions (2)
TL;DR: Reforms are identified that will be needed to the global health architecture to govern NCD risks, including to strengthen its ability to consolidate the collective power of diverse stakeholders, its authority to develop and enforce clear measures to address risks, as well as establish monitoring and rights-based accountability systems across all actors to drive measurable, equitable and sustainable progress.
Abstract: Non-communicable diseases (NCDs) represent a significant threat to human health and well-being, and carry significant implications for economic development and health care and other costs for governments and business, families and individuals. Risks for many of the major NCDs are associated with the production, marketing and consumption of commercially produced food and drink, particularly those containing sugar, salt and transfats (in ultra-processed products), alcohol and tobacco. The problems inherent in primary prevention of NCDs have received relatively little attention from international organizations, national governments and civil society, especially when compared to the attention paid to secondary and tertiary prevention regimes (i.e. those focused on provision of medical treatment and long-term clinical management). This may in part reflect that until recently the NCDs have not been deemed a priority on the overall global health agenda. Low political priority may also be due in part to the complexity inherent in implementing feasible and acceptable interventions, such as increased taxation or regulation of access, particularly given the need to coordinate action beyond the health sector. More fundamentally, governing determinants of risk frequently brings public health into conflict with the interests of profit-driven food, beverage, alcohol and tobacco industries. We use a conceptual framework to review three models of governance of NCD risk: self-regulation by industry; hybrid models of public-private engagement; and public sector regulation. We analyse the challenges inherent in each model, and review what is known (or not) about their impact on NCD outcomes. While piecemeal efforts have been established, we argue that mechanisms to control the commercial determinants of NCDs are inadequate and efforts at remedial action too limited. Our paper sets out an agenda to strengthen each of the three governance models. We identify reforms that will be needed to the global health architecture to govern NCD risks, including to strengthen its ability to consolidate the collective power of diverse stakeholders, its authority to develop and enforce clear measures to address risks, as well as establish monitoring and rights-based accountability systems across all actors to drive measurable, equitable and sustainable progress in reducing the global burden of NCDs.

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Cites background from "Sitting on the FENSA: WHO engagemen..."

  • ...While FENSA established rules of engagement between WHO and non-state actors, the framework has been criticised (by ourselves) as not containing sufficient guidance on governing the activities of industry in relation to public health outcomes [66]....

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