Navigating the Labyrinth of Public-Private Engagements for Global Nutrition
Malnutrition is everyone’s problem. After three years of steady increases, undernourishment is at 821.6 million. Concurrently, overweight and obesity rates continue to rise, reaching close to 2 billion globally. The private sector is a necessary link to malnutrition solutions, despite being part of the problem because of competing interests and a lack of transparency and trust. Public-private engagement can be a minefield of obstacles—hence the need for Together for Nutrition, an executive short course held in July by the Global Alliance for Improved Nutrition (GAIN).
I was part of the inaugural class, which included 26 diverse food and nutrition experts from around the world. Tough questions from our time together continue to resonate with me including how do we make better nutrition profitable? And how do we create products that fill nutrient gaps but also are desirable, available, affordable, and convenient? The concept of profitability is key when engaging businesses of all sizes to improve global nutrition. But profitability is not the focus for many stakeholders such as government, academia, nongovernmental organizations, and donors. This discrepancy in goals already puts potential partnerships across sectors at odds. So, what can we do in global nutrition to prioritize public-private engagements without them becoming a labyrinth?
Why Is Public-Private Engagement Such an Issue in Global Nutrition?
Engagement and formal partnerships with the private sector in global nutrition confront many hurdles—sometimes roadblocks—including lack of transparency, conflicts of interest, management and accountability, shared decision-making, resource parity, and unrealistic expectations. Nutrition is a unique field because of the scrutiny placed on engagement funding sources for research and program implementation. On one side of the coin, private sector companies develop foods and utilize marketing techniques that prevent optimal nutrition, such as sugar-sweetened beverages or breast-milk substitutes. On the other side of the coin, the private sector has the necessary infrastructure, innovation, and business acumen to seriously scale up nutrition initiatives.
Partnerships can be as complex as the problems they are trying to solve. But unlike other sectors, nutrition science and policy have a long history of stalled progress stemming from opposing views on what is most effective—and in the best interest of public health—in areas such as marketing, food production, recommended dietary guidelines, and labeling. Adding to the intricacy is the multidisciplinary nature of nutrition and conflicting outcomes. The global food system is an interrelated maze of social, agricultural, environmental, and economic considerations. In addition, the competitive struggle for increasingly scarce financial resources underlines the need to address the appropriateness and risks and benefits of public-private engagements.
As nutrition science evolves, the evidence base changes. In the early 1800s, when nutrition science was first conceptualized by French chemists interested in the oxidation of carbon, Francois Magendie said: “Nutrition has often been the subject of conjectures and ingenious hypotheses, but our actual knowledge is so insufficient that their only use is to try to satisfy our imagination. If we could arrive at some more exact facts, they could well have applications in medicine.” Much of this statement reigns true 200 years later because of human biological and sociological differences and the focus on single nutrients rather than a systems food-based approach.
Adding to the difficulties within scientific nutrition inquiry is the multitude of stakeholders, inconsistent research findings, and the long-term evaluations of interventions. Everyone is biased, and without a guiding scientific evidence base, there is no roadmap for profitable nutrition.
The Contribution of Small and Medium-Sized Enterprises to Profitable Nutrition
Local private sector companies are critical for profitable nutrition because they are a primary food source for many low-income households in the developing world, especially with the rise of urban populations. Securing funds for small and medium-sized enterprises (SMEs) is difficult as they are not large enough for commercial lending but are too large for microfinance. The lack of investment increases financial risks, causing SMEs to be overlooked as potential partners. A 2018 Food and Agriculture Organization of the United Nations and GAIN workshop report identified four priority action areas for SMEs to bring nutritious foods to markets: 1) facilitating the supply of nutritious foods by reducing production costs, 2) increasing the demand for nutritious food and marketing, 3) accessing to funds and investments, and 4) establishing a network of SMEs.
An SME that is making nutritious food profitable is Tarakwo Dairies Co., Ltd (Tarakwo) in Kenya. This farmer-owned milk cooperative was founded in 2010 as part of the East African Dairy Development program, a public-private initiative led by Heifer International and funded by the Bill & Melinda Gates Foundation and Elanco, and implemented by the World Agroforestry Centre, International Livestock Research Institute, and the African Breeders Service (ABS). Dairy provides high-quality animal proteins and fat and contributes to meeting daily recommended intake of micronutrients such as calcium, vitamin B12, and magnesium. Thus, why dairy consumption is encouraged for pregnant women and young children to reduce undernutrition and child stunting.
Because of the lack of profitability selling to large processors, Tarakwo started pasteurizing and selling milk directly to a large percentage of low-income consumers. With technical assistance from GAIN, Tarakwo sells milk through automated milk dispensaries, which operate much like ATMs. The competitive advantage of this novel approach is that the milk via the dispensers is affordable and reliable. Consumers can buy what they need or afford at any given time. Milk machines are profitable for Tarakwo and provide nutrition to consumers. In an affordability evaluation of the ATM intervention market compared to a controlled market, consumers perceived pasteurized milk to be cheaper with ATMs, that milk prices were on the rise because of a recent drought (but less so in the ATM market), and that changes in seasonal affordability were less drastic in the ATM market. This case study was presented during the course and served as a positive example of public-private engagement to make nutrition profitable.
No One Is Your Enemy . . . Make Friends . . . and Constantly Do Your Due Diligence
Two key messages from course speakers included those from 2018 World Food Prize laureate Dr. David Nabarro and Scaling Up Nutrition (SUN) Movement Coordinator Gerda Verburg. Nabarro started his remarks with “No one is your enemy.” He went on to explain that for public-private engagement to be successful, dialogue is necessary, and that blame should not be put on perceived past errors. Later in the week, Verburg added to Nabarro’s guidance by saying, “Make friends.”
However, one aspect was missing from this sage advice given by well-respected leaders in catalyzing change in global nutrition: constantly do your due diligence.
Whether an organization is entering into a broad engagement, formal partnership, or is a grantee, regularly vetting involved parties is crucial. Institutional reputations that can take decades to develop can be instantly crushed by one negative story that has legs. In the global nutrition space, multinational food companies are easily and rightfully blamed for both rising overweight and obesity trends and low breastfeeding rates. This is because of the marketing of sugar-sweetened beverages, highly-processed foods that lack nutritional quality, and little commitment to the International Code of Marketing of Breast-Milk Substitutes (i.e., the WHO Code). Private companies may have the resources and goodwill to curb malnutrition, but also business practices that contribute to seriously troubling global trends. Where does an individual or organization draw the line to engage or not to engage?
Nutrition affects every aspect of life. Other private sector stakeholders include finance, health, and agriculture. In order to reduce the massive funding gap to reach global nutrition targets, handshakes across sectors needs to be expanded beyond just food producers. The World Health Assembly (WHA) endorsed six global nutrition targets in 2012 to meet specified goals by 2025.
The World Bank calculated that an additional estimated $70 billion is needed over 10 years to achieve just four of the targets on stunting, anemia, exclusive breastfeeding, and wasting.
Multinational food companies are the natural fit for public-private engagement because of their inherent topical interest, expansive budgets, and need for positive corporate social responsibility stories. The global nutrition community is aware of the potential risks associated with multinational food company engagement. Less are aware of the potential reputational threats outside of the food sector.
This brings me back to my additional advice: vet everyone and vet often. While I was employed at The Sackler Institute for Nutrition Science at the New York Academy of Sciences (Sackler Institute) working on multi-stakeholder convenings in 2013, the Sackler family was not daily news. The Sackler family and their foundation—estimated at a net worth of $13 billion—built their fortune with the development and sales of OxyContin through their pharmaceutical company Purdue Pharma. No one could have predicted back then that OxyContin, a highly addictive painkiller, would be deemed as a cause of the U.S. opioid crisis or that Purdue Pharma and Sackler family members would be facing countless lawsuits. Even with the family being global philanthropists, grantees have since disaffiliated themselves from the Sackler name, and, recently, the Louvre removed the Sackler sign from its Oriental Antiquities wing. Purdue Pharma’s marketing techniques of OxyContin are under justified ethical scrutiny; and, while the connection may not be overt, parallels can be drawn to multinational food companies marketing breast-milk substitutes or sugary beverages and snacks to low-income consumers.
The Sackler family foundation supported nutrition financially because of the role nutrition plays in health and the lack of regulation compared to the pharmaceutical industry. The undeniable irony is that the Sackler Institute engaged with the food industry in various capacities while also engaging with the World Health Organization (WHO)—and managed the dynamics of those separate partnerships well. To provide additional guidance on industry-supported research, the Sackler Institute conducted a qualitative study on nutrition science neutrality that provided background and considerations for the development of Guiding Principles for Partnerships in Nutrition Science in 2016. This publication provided the institutional guidance necessary to maneuver the partnerships and funding relationships while limiting bias in science-related activities. According to the Wall Street Journal, the New York Academy of Sciences is discussing the family’s philanthropy, and the Sackler family members have left the board.
Evaluating the funding source is a common conversation among public health and international development professionals. Some feel that the donor does not matter as long as the money is used for positive outcomes. Others oppose funding loudly from certain sources. These perceptions are understandable and warranted. But like Nabarro stressed, the blame should not be put on perceived past errors. Because of the lack of funding in global nutrition, increased public-private engagement for nutritious and profitable food is a strong business case.
The Lack of Evidence-Based Recommendations for Public-Private Engagement
The scientific literature contains multiple frameworks for partnerships in global nutrition, but little research is published on their evaluation and application. Therefore, scientific-based recommendations are limited or anecdotal. To move forward, global nutrition organizations require more evidence on what works and what does not work in public-private engagements.
In the past five years, major global nutrition organizations and governments have developed their own engagement guidelines or policies. During the course, the conflict of interest presentation looked at the proposed risk management WHO tool developed in 2017 to prevent and manage conflicts of interest in policy development and implementation of nutrition programs. The tool uses a decision-making tree to evaluate the risks and benefits of possible engagement.
In 2018, the U.S. Agency for International Development (USAID) published its Private-Sector Engagement Policy, which defines private-sector engagement across a spectrum including donor-led, co-creation, and private-sector led. USAID views the private sector as an opportunity to end the need for foreign aid through market-based approaches and enterprise-driven development. The operational principles include: 1) engage early and often, 2) incentivize and value private-sector engagement throughout planning and programming, 3) expand the use of USAID approaches and tools that unlock the potential of the private sector, and 4) build and act on the evidence of what works and what does not, in private-sector engagement.
Although the Private-Sector Engagement Policy is an encouraging move toward broadening U.S. government foreign policy engagement, implementing the policy will take years and a major cultural shift in how USAID interacts with the private sector. Principle Four—build and act on the evidence of what works and what does not work—will be the true challenge evidenced by the lack of USAID-funded nutrition intervention outcomes. Mid- to long-term nutrition intervention outcomes are not tracked at the country level, making the evaluation of private-sector engagement impact, adaptive management, and learning an idealistic dream that may not be obtainable.
Quintessential to public-private engagement is utilizing creativity to systematically apply each partner’s strengths to maximize outcomes. Inventive engagement frameworks have the potential to make sustainable impact in research, policy, and practice. Like systems thinking, the idea is that the sum is greater than its parts. Evaluations of the engagement and the engagement’s intended outcomes are crucial for long-term success.
In an era of limited economic resources, increased conflict and climate shocks, and a growing population, organizations across the food system must align resources to confront malnutrition. One strategic mechanism is to collaborate to make nutrition profitable, which is why the Together for Nutrition course was a timely and vital resource. Open dialogue and the sharing of experiences are ways to learn from each other.
Special thanks to those who participated in Together for Nutrition. The presentations and discussions provided the basis for this commentary.
Amy R. Beaudreault, PhD, is a research fellow with the Global Food Security Project and the Global Health Policy Center at the Center for Strategic and International Studies in Washington, D.C.
Commentary is produced by the Center for Strategic and International Studies (CSIS), a private, tax-exempt institution focusing on international public policy issues. Its research is nonpartisan and nonproprietary. CSIS does not take specific policy positions. Accordingly, all views, positions, and conclusions expressed in this publication should be understood to be solely those of the author(s).
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