Appendix 7: Public Health Responsibility Deal
This summary is based on an accountability framework to promote healthy food environments (6) (see Figure 1), as previously applied to the calorie reduction pledge from the Public Health Responsibility Deal (7). The INFORMAS monitoring framework (8) has also been used to structure the summary of impacts of the Responsibility Deal (see Figure 2).
Introduction
- The Public Health Responsibility Deal (RD) was a voluntary public-private partnership established by the UK Coalition Government 2011-2015, aiming to tackle public health challenges in England using a collaborative approach (9)
- The RD involved networks for alcohol, food, physical activity and health at work, with a behaviour change network providing expert advice across the RD as a whole
- Each network was composed of a core group including government, commercial and voluntary organisations, and academic experts, and was underpinned by iterative and collaborative development of pledges (commitments) to improve the public’s health
- The RD was based on a premise that governmental top-down approaches do not lead to improvements in public health, and that partnerships are more effective and efficient than regulation in enacting public policy changes (10)
- The initiative may also have been influenced by the behavioural economics theory of ‘nudging’ people to engage in healthier behaviours through small modifications to the environment in which they make choices (their ‘choice architecture’) (11)
1. Take the account (assessment)
- Organisations self-monitored their progress against the pledges they chose to sign up to, and were requested to provide annual updates to the UK Department of Health
- The lack of a transparent monitoring and verification process for pledges, and emphasis on ‘nudging’, caused discontent from the outset. Public health organisations were concerned that potential benefits to public health had been made subordinate to the interests of industry, and that alternative courses of action had not been identified by the government, should the pledges fail to be successful (12)
- Independent evaluations of the RD by the Policy Innovation Research Unit (PIRU) group at the London School of Hygiene and Tropical Medicine identified major shortcomings of the initiative (13-18)
- Key concerns across the RD networks were: absence of approaches known to be most effective in improving public health from the agreed RD pledges; small number and heterogeneity of organisations’ progress reports, leading to difficulties in assessing the quality and extent of implementation of interventions captured by pledges; and the majority of such interventions had already been initiated, or were likely to have been implemented anyway, irrespective of the RD (13-18)
- Many organisations’ drive to participate in the RD appeared to be drawn from the opportunity to improve their reputation, achieve corporate social responsibility goals, and avoid external regulation (16)
2. Summary of key impacts of the RD, with focus on obesity
- Food composition (no formal evaluations were undertaken as part of the RD; specific targets, where mentioned in pledges, are presented)
- Calorie reduction (target to reduce population consumption by 5 billion calories/day, ie approximately 100 calories per person) – no significant change for adults from 1896 to 1849 kcal/day, 2008/9 to 2013/14 (19)
- Saturated fat reduction (target for less than 11% daily food energy intake per person) – no significant change for adults from 12.8% to 12.7%, 2008/9 to 2013/14 (19)
- Trans fat reduction (target for complete removal from products) – change for adults from 1.5g/day (0.7% total energy) to 1.0g (0.5% total energy), 2008/9 to 2013/14 (19)
- Salt reduction (target less than 6g per person/day) – no significant reduction for adults from 8.5g to 8.0g/day, 2011 to 2014 (20)
- Fruit and vegetable intake – no significant change for adults from 4.1 to 4.0 mean portions/day, 2008/9 to 2013/14 (19)
- Sugar reduction programme launched in the Conservative Government’s 2016 childhood obesity strategy, aiming to reduce sugar intake by 20% by 2020, through reduction of sugar levels in products, reducing portion size and shifting purchasing towards lower sugar alternatives (21). Sugar content targets for foods and drinks will be published by Public Health England in 2017
- Food labelling
- Front-of-pack nutrition labelling – new voluntary labelling scheme established in 2013, with organisations accounting for almost two thirds of food on sale signed up (22)
- Out-of-home labelling – one third of meals and takeaways sold on the high street covered by organisations signed up to calorie labelling (22)
- Food promotion
- No specific RD pledges developed
- Separate Committee of Advertising Practice consultation undertaken in 2016 evaluating whether a ban on advertising junk food to children online, in the press, on billboards and poster sites should be introduced (23)
- No guidance or legislation introduced in the 2016 childhood obesity strategy (21)
- Food provision
- Implementation of basic measures for encouraging healthier food availability in the workplace – no formal evaluation
- Food retail
- Food prices
- No specific RD pledges developed
- Separate Soft Drinks Industry Levy planned for 2018 (26)
- Food trade and investment
- No specific RD pledges developed
- Physical activity
- No formal evaluations of quantitative changes in physical activity; robust national data for comparisons not available post-2012
3. Share the account (communication)
- Progress was noted by the UK Department of Health in terms of engagement, with 776 partner organisations signed up to the RD across 43 pledges, over four years. However, organisations’ progress reports were generally descriptive rather than providing quantitative data; largely reflected implementation instead of outcomes; and were inconsistently submitted (13, 15, 17)
- Meeting documentation for the RD was criticised for being insufficiently transparent (15). An analysis of the calorie reduction initiative of the RD required Freedom of Information requests to access source material, which was not routinely uploaded to the RD website (27)
- The UK Department of Health promoted successes of the RD at a celebratory event in March 2015 (22); however overall, government communications regarding RD outcomes were scant
- Media coverage of the RD in both scientific and non-scientific fora was generally negative (for example (28-31))
4. Hold to account (enforcement)
- An independent scoping review of 47 voluntary agreements between business and government indicated that although such agreements may provide an effective approach when appropriately implemented and monitored, the evidence base regarding their comparative effectiveness with compulsory or legislative strategies is lacking (32). Sanctions for non-compliance and disincentives for non-participation often featured in the most effective voluntary agreements (32)
- However, incentives and disincentives were not characteristics of the RD, and the UK Government did not publicise any plans to advance progress through enforcement
- A study of informants’ experiences of the RD concluded that in order to produce true gains to public health: “government needs to increase participation and compliance through incentives and sanctions, including those affecting organisational reputation; create greater visibility of voluntary agreements; and increase scrutiny and monitoring of partners’ pledge activities” (16)
- The RD was criticised by several NGOs, such as Action on Sugar (33), Institute of Alcohol Studies (34), Sustain (35) and Which? (36) for lack of progress and transparency
- Other strategies such as shareholder advocacy and litigation were not used to hold non-compliant and under-performing organisations to account
5. Respond to the account (improvements)
- Since the election of a new UK Conservative Government in 2015, the RD has not been actively pursued
- There has been little evidence of collaboration between RD organisations, UK Government and NGOs to achieve pledges
- An independent monitoring system would appear necessary to ensure transparency, and guide implementation of incentives and penalties, policies and regulations, and legislation to hold organisations to account
- Robust mechanisms to translate findings from evaluations and civil society pressure into tangible changes to government policies and organisational practices should be developed
Limitations:
The Responsibility Deal was a useful way of bringing stakeholders together, reaching agreement on certain issues, most of which were already underway to some extent within the industry (eg. removal of trans fats). It did, however, fail to take forward more challenging and contentious issues of appropriate and desirable reductions, for example in salt, sugar content, and labelling. There was insufficient clarity over what government expectations were and what success would look like.
There was also a lack of government ‘commentary’ on the appropriateness of the response by companies, either in terms of who was/ was not making a commitment or the appropriateness/ relevance of their response once they did pledge. The RD relied on industry members agreeing to ‘pledges’ to take actions to contribute to tackling obesity and diet-related disease. As a result the wording of the pledges was generally unambitious and allowed for a great deal of flexibility. The Royal Society for Public Health, Faculty of Public Health and several other professional bodies withdrew their interest and support from the RD at an early stage. Many public health organisations also publically withdrew from the Alcohol group. In view of recent political changes and focus on other issues such as Brexit, the RD has fallen much lower down the political priority agenda. Maintaining momentum for initiatives such as this can be challenging, and the RD is unlikely to be resurrected in its previous form.
What should be done to make it work better in other countries?
- A clear timetable for action, and clarity over steps that will be taken if there is not enough progress, is needed at the outset
- Voluntary initiatives alone will not achieve change on the scale needed to address issues of diet-related disease. Such action needs to be supported by other government initiatives, including legislation where necessary
- A fair, level playing field is required for industry members. There should be public reputational sanctions for those who do not commit (eg. a naming, praising and shaming approach), in order that participation/ commitment is not de-incentivised
- Senior level commitment by government, industry and public interest stakeholders is needed, to promote buy-in, ensure momentum, and hold participants to account.
Figure 1: Accountability framework to promote healthy food environments (6)
Figure 2: INFORMAS monitoring framework (8)
Appendix 8: UK structured approach to reducing sugar in the food supply
After adopting the WHO recommendations to reduce population intake of free sugars to 5% of dietary energy, the UK embarked on a program of action to reduce sugar consumption, acting on both the demand for, and the supply of, sugar in processed foods.
Demand is being countered through a variety of measures, including consumer education and social marketing, restrictions on advertising of high-sugar foods to children, and the introduction in 2018 of a levy on sugar-laden beverages. The levy is designed to encourage reduction in sugar content by applying a two-tier penalty: 18 pence per litre for non-milk drinks with added sugars between 5g and 8g per 100ml, and 24 pence per litre for non-milk drinks with a higher sugar content.
Supply is also being tackled directly through three innovative measures: 1) reducing the sugar content of widely consumed foods, 2) reducing the portion sizes of these foods, and 3) encouraging manufacturers to change their sales portfolios from higher to lower sugar content foods. A target of 5% reduction in total sugar consumption in 2017 compared with 2015, increasing to a 20% reduction by 2020 has been set and is being monitored. The 20% reduction in five years is an ambitious target for such a short time frame. However, this is only a third of the 60-67% reduction needed to reduce consumption from 12% of dietary energy for adults in 2015, and 15% dietary energy for older children, down to WHO recommendations.
The government strategy for holding industry to account involves detailed analysis of sales-weighted data for the leading sugar-containing foods in the current UK diet.(37) Data are converted into targets for the mean, average and range of sugar levels in each of 11 categories (spanning baked goods and breakfast cereals to confectionery and soft drinks). The targets may be met through a combination of the three approaches: reduced sugar content, reduced portion size and reduced sales of the higher-sugar containing product lines.
Targets are also set for a range of out-of-home catering services.
Sanctions against failure to meet these targets have not yet been established. However the willingness of the UK government to consider interventions directly affecting soft drink marketing, and to impose restrictions on sales of soft drinks and confectioner in public sector premises such as hospitals and schools, may indicate that all sectors of the food market are potentially vulnerable. Food companies that act first may therefore be the ones to gain the best market advantage.
Public Health England have released their report on first year progress. General consensus appears to be that some progress has been made, but this has been limited, and has fallen short of the 5% reduction target. (https://www.gov.uk/government/publications/sugar-reduction-report-on-first-year-progress)
Appendix 9: Urban agriculture in Havana
Havana, Cuba, is a notable example of where urban agriculture has been promoted to greatly increase the supply of fresh healthy fruit and vegetables. In Havana, residents converted patios, rooftops, and unused parking lots into vegetable allotments. The land was cultivated with manual labour and organic waste. The Cuban Ministry of Agriculture programmes educated urban cultivators in methods of permaculture, composting, and the use of biological pest control.
Co-operatives were established, owned, and managed by city dwellers, encouraging the trade of other scarce items such as seeds and tools. Local kiosks were set up as farmers’ markets in every community, trading local provisions and eliminating the need to travel and reducing the carbon footprint. Cuba now grows 90% of its fruits and vegetables, with 4 million tonnes of vegetables every year from urban allotments in Havana alone.(38-41) Increased local production of food can potentially improve access of residents to fresh fruit and vegetables while simultaneously cutting down on carbon emissions due to reduced need for processing, packaging and transportation. This potentially has a major impact on climate change, as food may account for 40% of all road freight.(42) In addition, urban heat island effect is reduced, resulting in less energy for cooling.(43) Urban agriculture can potentially help diversify local economies.(43) In order to ensure that low-income residents can participate in urban agriculture it is important to provide support, such as access to credit.(44)
Appendix 10: Physical activity recommendations, drawn from the WHO Global Action Plan on Physical Activity (2017), scored for potential impact on climate change mitigation and adaptation*
| Physical activity domain | Recommendations | Potential Climate Change Impact | |
| Mitigation | Adaptation | ||
| Implement communication campaigns to raise awareness of the multiple benefits of physical activity | Develop a national communication strategy for the health benefits of physical activity | 2 | 1 |
| Implement sustained public education, awareness and behaviour change campaigns to promote physical activity | 3 | 2 | |
| Use sport, arts, cultural, health and other participatory events to promote physical activity | 2 | 1 | |
| Support partnerships between health and other sectors to engage in promotion events to raise awareness of physical activity | 2 | 2 | |
| Conduct communication campaigns to increase knowledge of the multiple co-benefits of physical activity | 2 | 2 | |
| Support national, regional and international campaigns on issues related to physical activity | 2 | 1 | |
| Implement mass-participation initiatives and provide access to physical activity experiences | Implement accessible events that provide opportunities to be active in local public spaces activities | 2 | 2 |
| Develop and disseminate national guidance and examples on how to implement mass participation initiatives on physical activity in public open spaces | 2 | 2 | |
| Strengthen training of health and non-health professionals in opportunities to develop an active society | Strengthen curricula of all medical and allied health professionals for effective integration of the health benefits of physical activity into formal training | 2 | 2 |
| Strengthen formal training for preschool, primary and secondary school teaching staff and administrators to strengthen knowledge and teaching skills on physical activity | 2 | 2 | |
| Include physical activity in the professional education of relevant sectors outside of health to understand the value of promoting physical activity | 2 | 2 | |
| Partner with road safety experts to strengthen stakeholders’ understanding of safe systems approaches to improving road safety for pedestrians, cyclists and public transport users | 3 | 1 | |
| Promote active and public transport through policies and infrastructure | Prioritize walking, cycling and public transport as preferred modes of travel in relevant transport, spatial and urban planning policies | 4 | 2 |
| Support health and economic assessments of transport and urban planning policies and interventions to assess impact on health, physical activity and environment | 4 | 1 | |
| Support the development and implementation of planning and transport policy, guidelines and regulations that promote active and public transport | 4 | 1 | |
| Strengthen health in all policies at the national and subnational level, focusing on issues related to physical activity in relevant policies across key sectors | 2 | 2 | |
| Support the effective engagement of communities in direct participation in urban and transport planning processes | 3 | 2 | |
| Increase the level of service of well-connected walking and cycling networks | 3 | 2 | |
| Promote integrated urban design and land use policies that create highly connected, walkable neighbourhoods | 3 | 3 | |
| Develop policies to support ‘co-location’, enabling efficient access by walking, cycling and public transport | 4 | 2 | |
| Support the strengthening of national road safety legislation and action plans | 2 | 1 | |
| Support the strengthening of road transport safety systems | 2 | 1 | |
| Increase the level of service of well-connected walking and cycling networks | 3 | 1 | |
| Implement education and social marketing campaigns aimed at increasing safe behaviours among all road users | 2 | 1 | |
| Encourage urban planning policies and strategies that reduce crime and the fear of crime, to facilitate increased active use of open public and private spaces | 2 | 1 | |
| Strengthen access to recreational spaces and facilities for all | Promote and enforce urban planning, land use and spatial policy that enables access to open spaces, green spaces, and sports facilities | 2 | 2 |
| Implement health and economic assessments of open spaces to evaluate health, climate and environmental benefits, including impact on physical activity | 3 | 3 | |
| Facilitate active engagement of community members in the location, design and improvement of open and recreational spaces | 2 | 3 | |
| Strengthen the policy of shared use of school facilities to increase provision of open public spaces for community utilization | 2 | 2 | |
| Strengthen the implementation of market restrictions on unhealthy food and non-alcoholic beverages in and around open public spaces and sports facilities | 2 | 1 | |
| Strengthen guidelines and frameworks to promote physical activity in and around buildings and facilities | Support the development and implementation of building design guidelines and regulations that prioritize universal access, and physical activity amongst occupants and visitors | 2 | 2 |
| Develop and implement design guidelines for education and child care facilities that optimise provision of environments for children and young people to be physically active | 1 | 2 | |
| Develop and implement design guidelines for recreational and sports facilities that ensure equitable, safe and universal access by all people | 2 | 2 | |
| Strengthen provision and enjoyment of good-quality physical education and active recreation | Strengthen national education policy, implementation and monitoring to ensure provision of quality, inclusive physical education for school-aged children | 1 | 1 |
| Strengthen national implementation of whole-of-school physical activity programmes in all education institutions | 2 | 1 | |
| Promote walk and cycle to school programmes | 3 | 2 | |
| Develop and disseminate guidance for childcare regulators and providers on promoting physical activity in childcare settings through the day | 1 | 1 | |
| Collaborate with the higher education sector to develop leadership and engagement in strengthening provision of opportunities to increase physical activity | 1 | 1 | |
| Implement patient assessment, advice and referral for physical activity into health and social care services | Develop and implement national standardized protocols on patient assessment and brief advice on physical activity in primary health and social care settings | 1 | 2 |
| Integrate patient assessment, brief advice and referral to opportunities for physical activity as part of the care and services for older patients, those with long term conditions, and pregnant women | 1 | 2 | |
| Enhance provision of, and opportunities for, physical activity in wide-ranging work and leisure settings | Provide national leadership by implementing whole-of-government workplace health initiatives to support increased physical activity | 1 | 1 |
| Develop and disseminate national guidance, and promote implementation of workplace health programmes aimed at increasing physical activity amongst employees | 1 | 1 | |
| Partner with Ministries of Sport and the sports community to strengthen provision of universally accessible active recreation and sports programmes | 2 | 1 | |
| Partner with subnational and local governments to promote the use of existing public community buildings and facilities for community-based physical activity programmes | 2 | 2 | |
| In partnership with education, health and childcare sectors, implement programmes aimed at families, parents and caregivers to develop skills to help young children enjoy active play | 1 | 1 | |
| Partner with Ministries of Finance to review and evaluate the effectiveness of fiscal instruments to promote physical activity as a way of life | 1 | 1 | |
| Strengthen programmes and services that engage with and increase opportunities for physical activity in the least active groups | Strengthen implementation of national standardized protocols for assessing physical activity capacity in older adults and providing brief advice in primary and secondary health care | 1 | 1 |
| Develop and implement national policy to strengthen provision of appropriate programmes to increase physical activity amongst older adults | 1 | 1 | |
| Develop and implement interventions supporting families and caregivers to acquire the skills, competencies and confidence to support healthy ageing in and outside the home | 2 | 2 | |
| Ensure that data are reported and used to identify the least active subpopulations, and to engage representatives in development of tailored programmes to increase participation | 1 | 1 | |
| Support the development and implementation of programmes promoting physical activity in disadvantaged, marginalized and indigenous communities and populations | 2 | 1 | |
| Support development of national sports policies prioritizing investment in active recreation and sports programmes targeting the least active, and disadvantaged groups | 2 | 1 | |
| Support partnerships with the sports sector to promote universal access to opportunities for physical activity for all people with disabilities and their carers | 1 | 1 | |
| Implement whole-of-community initiatives to promote widespread participation in physical activity | Strengthen national and subnational networks of communities implementing whole-of-community approaches to promote physical activity, and share resources and experiences | 2 | 2 |
| Implement city scale and whole-of community, multi-component approaches to promoting adequate physical activity for all, using principles of community engagement | 3 | 2 | |
| Disseminate implementation guidelines and incentives to encourage whole-of-community physical activity initiatives at subnational level | 2 | 2 | |
| Strengthen leadership, governance and policies to increase physical activity | Strengthen high level national multi-sectoral coordination committees providing leadership, strategic planning and oversight of national policy actions on physical activity | 2 | 2 |
| Strengthen national and subnational action plans on physical activity which align with global and regional recommendations, and maximize policy coherence and synergies across key relevant sectors | 2 | 2 | |
| Partner with other sectors to strengthen the position of physical activity within respective policy frameworks | 2 | 2 | |
| Review, adopt and update national physical activity guidelines, and disseminate through tailored resources adapted to target audiences and local context | 1 | 1 | |
| Foster leadership to promote policy action on physical activity and stimulate professional and community-wide shift towards positively valuing an Active Society | 2 | 2 | |
| Enhance data systems and capabilities to support surveillance, monitoring and accountability for physical activity | Strengthen population surveillance of physical activity, ensuring coverage of all ages and domains, and regular reporting of progress towards achieving targets | 1 | 1 |
| Strengthen data analyses and dissemination to inform priority setting, and support monitoring of progress towards reducing inequalities in participation in physical activity | 2 | 2 | |
| Adopt a set of harmonised national and subnational targets and indicators as part of a national monitoring and evaluation framework to track progress towards reducing physical inactivity | 2 | 2 | |
| Support partnerships to develop innovative digital technologies to strengthen surveillance of physical activity and its determinants | 2 | 3 | |
| Strengthen research and evaluation capacity and strengthen innovations for policy solutions to increase physical activity | Strengthen government and nongovernment funding support for research on physical inactivity and sedentary behaviour | 1 | 1 |
| Identify and disseminate a set of national research priorities for physical inactivity and sedentary behaviour | 1 | 1 | |
| Support research institutions to ensure appropriate level of evaluation of all national and subnational physical activity policies and programmes, and disseminate findings | 1 | 2 | |
| Strengthen innovation, evaluation and knowledge sharing to ensure that evidence on physical activity is widely accessible and can advance policy implementation and resource use | 1 | 2 | |
| Collaborate with relevant centres and research organizations to strengthen knowledge transfer and institutional capacity for research and program evaluation on physical activity | 1 | 2 | |
| Escalate advocacy efforts to increase action at multiple levels, targeting key audiences | Support the creation of networks and collaborative actions to empower people and communities to be engaged with the development of an Active Society | 2 | 2 |
| Strengthen partnerships with civil society, community organisations, the media and private sector to raise awareness and support engagement to increase physical activity | 2 | 2 | |
| Strengthen financing mechanisms to support action and policies to increase physical activity | Allocate long term budgets for physical activity, taking account of national targets and priorities | 2 | 2 |
| Collaborate across Ministries to develop dedicated financing mechanisms to support multi-sectoral approaches and policy actions on physical activity | 2 | 2 | |
* Rating 1= no impact to 5 = substantial impact
Appendix 11: Analysis of the global governance for nutrition
A recent analysis completed for the UN System Standing Committee on Nutrition (UNSCN), identified 167 actors as prominent in global nutrition governance (Figure 6).(45) While no single UN agency is responsible for nutrition, agencies are tightly connected via two UN-wide platforms/networks – the UNSCN and the Committee on World Food Security (CFS). The WHO and FAO are the lead agencies mandated to coordinate actions over the ‘malnutrition in all its forms’ focused UN Decade of Action on Nutrition (2016-2025), which sits within the broader framework of the Sustainable Development Goals. A number of other influential nutrition-focused UN system platforms have emerged in recent years, each governed variously by actors from within the UN system, private sector, NGOs and national governments. These provide a convening function to harness technical expertise, financial resources, and provide on-the-ground support for policy implementation and capacity building. A significant and relatively new multi-stakeholder partnership is Scaling Up Nutrition (SUN). Established in 2010, SUN brings together governments, civil society and the private sector. The Inter-Agency Task Force on the Prevention and Control of Non-Communicable Diseases (IATF) coordinates the activities of relevant UN and other inter-governmental organizations to support national governments to meet their high-level commitments on addressing diet-related NCDs.
While nutrition may not be their primary mandate, other important and economically powerful actors are active in the nutrition area. Multilateral agencies and financial institutions e.g. the World Bank, and private philanthropic organizations, particularly the Bill and Melinda Gates Foundation and Bloomberg Philanthropies, feature prominently in the global landscape, as do a number of public-private partnerships, multinational corporations and corporate foundations. The increased concentration of transnational food corporations in the global nutrition landscape poses questions of how to identify, mitigate and manage potential conflicts of interest. There is also a diverse set of non-government organizations with interests spanning food security, food sovereignty, micronutrient deficiencies, obesity and diet-related NCDs. These different foci play important roles in shaping policy agendas and enabling networks of different actors to coalesce around shared interests. Many new research institutions have emerged, a number of which bridge connections between food systems, nutrition and environmental sustainability, which have potential to facilitate a shift in the global, regional and national policy discourses and agendas.
Network map of actors involved in the global nutrition governance system, colour coded by type
Appendix 12 Criteria for new global health treaties and counter-arguments
| Criteria | Hoffman et al. 2015 assessment | Counter arguments |
| Nature of the problem: significant transnational dimension (Involves multiple countries, transcends national borders, and transfers risks of harm or benefit across countries) | Except for trade dimensions, mostly requires domestic action | Involves multiple countries as the main conflicted businesses are multinational and unhealthy foodstuffs can be sold worldwide through imports/exports. Online marketing is cross border and difficult to regulate if policies are adopted only by one or a few countries. Trade policies, such as TTIP and CAP, are transnational. |
| Nature of the solution: coercive nature of treaties justified (addresses multilateral challenges that cannot practically be addressed by any single country alone, resolves collective action problems when benefits are accrued only if multiple countries coordinate their responses, or advances superordinate norms that embody humanity and reflect near-universal values) | Does not meet requirements justifying coercion | Added to the previous arguments is cross-border lobbying e.g. Italy complains to EU over Britain’s food labelling (traffic lights) impact on Italian products sold in UK supermarkets. Global policies can be weakened by lobbying from one Member State. If all Member States have signed up, this is less likely to happen. |
| Nature of likely outcome: reasonable chance of achieving benefits (Incentivizes those with power to act, institutionalizes accountability mechanisms designed to bring rules into reality, and activates interest groups to advocate its full implementation) | Few incentives and likely weak accountability | If a package of policies is promoted (e.g. by WHO) it will address totality of the food environment, rather than bit by bit in different countries. Accountability could be easy if a single company is internationally held to account rather than its national branches. This will also tackle the double standards between global north and south that many food companies adopt. |
| Nature of implementation: best commitment mechanism (Projected to achieve greater benefit for its costs than competing alternative mechanisms for facilitating commitment to international agreements) | No evidence that a treaty is better than alternatives | National piecemeal approaches will not work and a policy package is needed to address imports/exports, cross-border practices and trade agreements. International mechanism drives innovation for healthier food alternatives and creates incentives. |
Source: Hoffman SJ, Røttingen J-A, Frenk J. Assessing proposals for new global health treaties: an analytic framework. Am J Public Health. 2015;105(8):1523-30 (reference 46).
