Strengthening public sector governance
By governance we mean the organised efforts to manage the course of events in a social system.173 Governance includes the totality of “political, organisational, and administrative processes through which stakeholders, including governments, civil society and private-sector interest groups, articulate their interests, exercise their legal rights, make decisions, meet their obligations, and mediate their differences”.174
We present four key governance challenges for addressing The Global Syndemic. Effective governance will require coherent action across diverse sectors from global to local levels, strong commitment from all relevant stakeholders, sufficient capacities and resources to enable and sustain such action, and the attenuation of systematic power imbalances within food systems. These challenges are contextualised against a backdrop of contemporary changes in global, national, and local governance systems.
Governance challenge 1: driving coherent action
Addressing the drivers of The Global Syndemic requires coordinated and sustained action within and across many sectors — health, agriculture, environment, finance, transportation, economic development, and urban planning among others — from global to local levels.
Achieving coherence has presented a considerable challenge. WHO and other expert bodies identify a hybrid approach to food and nutrition governance — multi-stakeholder or public-private partnerships — as a key mechanism for addressing the complexity of this challenge.175 However, such arrangements have raised concerns regarding conflicts of interest, the conflation of private interests with citizen’s interests and rights, and power asymmetries in decision making. Existing evaluations show mixed results, varying by issue, nature of the engagement, complexity of the governance structure, and diversity of partners and interactions.175, 176 Similar challenges exist at the global level (appendix p 32). Some actors have an explicit mandate to improve nutrition, whereas other actors do not. Some focus on undernutrition and food security, and others focus on obesity and diet-related NCDs. This institutional complexity increases the potential for divergent interests and world views, competition for resources, and duplication of efforts. It reflects broader contemporary changes in the global health governance system since the 1990s, particularly the substantial increase in the number and diversity of actors who are involved in global governance.177
At the country level, experiences suggest that a more state-anchored approach can drive multisector or multilevel actions that involve empowered government-coordinating agencies, well designed policies, and institutional systems. Successful efforts at reducing undernutrition in several countries have included governance bodies and coordinating agencies with sufficient authority, capacities, financial resources, and leadership, and line agencies (eg, health, agriculture, and education) responsible for implementation. The direct participation of high-level political champions and the existence of non-partisan parliamentary coalitions for nutrition have further strengthened and sustained responses across cycles of political change. Strong incentives have helped drive coherence, including inclusive governance bodies for civil society and stakeholder engagement, legislation that mandates cooperation, and shared indicators and targets that are sector-specific and time-bound. In some cases, performance-based or results-based budgeting has incentivised cooperation and improved transparency and accountability.178, 179 The UN Decade of Action on Nutrition (2016–25) provides an important umbrella framework to galvanise action, and the strengthened Committee on Food Security is a key forum to coordinate actions that address malnutrition in all its forms.
Governance challenge 2: generating and sustaining commitment
Commitment is the willingness for people and institutions to act until the job is done. Credible and sustained commitment from political leaders who champion policy initiatives, government officials who coordinate action, civil society groups who advocate for attention and resources, and affected community groups and individual citizens is crucial to drive coherent policy responses.180, 181 Interventions that target obesogenic food environments and food systems are frequently and systematically undermined by the coordinated efforts of powerful food and beverage industry groups.181 Rhetorical commitments to address undernutrition have not been supported by policies, coordinating structures, and financial resources owing to ineffective civil society pressure, limited visibility of the issue, and weak public demand.178, 180 In relation to undernutrition, policies that emphasise agricultural commercialisation, cash-cropping, and economic growth (ie, productivism) have impeded more balanced nutrition-sensitive policies that would promote dietary diversity and meet local nutritional needs.181, 182
Even more challenging is the inclusion of food and agriculture within the commitments on climate change under the 2015 Paris Agreement. The collective efforts to increase trade through multiple rounds, from the General Agreement on Tariffs and Trade established in 1947 to the World Trade Organization, have struggled to include agriculture in the process to reduce tariffs, quotas, and subsidies. This same political struggle happened again in climate change commitments. The enormous political power of the food and agricultural system industries has consistently overwhelmed individual and collective government efforts to promote the public interest rather than commercial interests.
What can drive and sustain commitment across all actors? Studies have identified a web of drivers, including political champions (eg, heads of state, cabinet members, and parliamentarians) and non-partisan support (ie, multi-party or multi-faction) at the highest levels.178, 181, 183 Mobilised civil society is also a considerable driver. Civil society coalitions, including non-government organisations and informal social movements, have had important roles in generating attention, informing policy processes, and sustaining political commitment for food policies.184 These civil society actors have crucial roles in governance by raising public awareness, giving voice to politically marginalised groups, holding governments accountable for public policies,178, 185 and informing policy development, monitoring, and evaluation.178, 183, 184 These roles are enhanced in the context of inclusive governance arrangements that connect such groups (including policy beneficiaries) with decision-makers, and by legal commitments in international human rights treaties endorsed by governments (discussed in the Right to wellbeing section). In short, an active civil society can have a key role in strengthening the accountability, inclusiveness, transparency, and responsiveness of governance systems. For example, the mobilisation of a cohesive civil society coalition was crucial in driving commitment for a sugary drinks tax in Mexico (panel 7).
Governance challenge 3: mobilising capacities and resources for impact
Governance for addressing The Global Syndemic will require commitment and coherence of action, but also the capacity and resources to act. In many countries, weak organisational capacities — including the absence of trained professional and administrative staff, the high administrative burden of working with diverse stakeholders, weak budgeting and accounting systems, and poor technical capacities — have undermined planning activities, programming efficiency, and the accountability of governing institutions related to undernutrition.178, 186 Another crucial and overlooked aspect is strategic capacity — the soft-power and interpersonal skills required to drive collective action across diverse actor networks. Strategic capacity includes the capacity to build coalitions, manage conflicts, respond to emerging opportunities and threats, manage complex policy processes, and undertake strategic communication.178, 184, 187 The absence of line items for undernutrition in government budgets, inadequate budgetary allocations, or the failure to use finances (particularly at subnational levels) has often resulted in policy failure.180 Panel 10 presents a case study of Kisumu Kenya showing how capacity and resource limitations and the fragmentation of governance among large numbers of stakeholders can hinder urban food governance in developing countries.
Urban governance in many cities throughout the developing world involves a wide range of actors, often with limited capacities and conflicting agendas, and with few processes for collaboration or reaching consensus.188 The city of Kisumu in Kenya, Africa, offers an example. The rushed and partial decentralisation of public authority in Africa in the past few decades has often resulted in local governments that are “weak, disorganised, inadequately trained and staffed, and often under-resourced relative to their expected range of responsibilities.”189
The food retail sector in African cities operates independently of government control, adding to the governance challenge. The wide variety of food retailers include traditional market places, shops and kiosks, and street food vendors. Market places are a particularly important element of urban food systems in Africa and are an important site of urban governance. In Kisumu, most food is bought and sold in the city’s many urban markets, which provide employment for approximately 60% of the city’s labour force.190 The municipality collects fees from traders but provides little in return.
Like other parts of Africa,191, 192 the number of supermarkets in Kisumu has increased rapidly. Although their governance will be of increasing importance, local government control over where supermarkets are located, their design, or what they sell has been limited. The implications of this transformation for urban food security are not well understood. However, the shift from local food production and an informal retail sector to formal supermarkets with international supply chains might result in decreased food security due to higher and less flexible prices and increased amounts of processed foods.148
The diversity of actors can be both a challenge for governance and an opportunity to mobilise additional skills and resources to address urban food and nutrition problems. In this regard, there have been repeated calls for collaborative governance — bringing multiple stakeholders together in common forums with public agencies to engage in consensus-orientated decision making193 — and for the co-production of projects and policies by a range of urban governance actors.194 In Kisumu, the Kisumu Action Team and Kisumu Local Interaction Platform have convened stakeholders to pool skills and resources and develop a number of ambitious strategies for Kisumu, such as upgrading market places and improving urban food security,195 exemplifying the potential for stakeholders to begin to work together through collaborative governance.
The expansion of government budgetary commitments and establishing effective financing systems, through donor support and technical assistance, is important for empowering governing institutions and implementing agencies, mobilising human resources, and establishing entitlements among government officials, interest groups, and citizens that generate continued political support.178, 196, 197 Such governance might also include policy mechanisms that provide technical and financial support for under-resourced subnational governments and other implementation partners.178 As with Kisumu, collaborative governance arrangements can bring together a diverse range of stakeholders to pool resources and collaborate on developing holistic and inclusive strategies. Capacity-building initiatives might also include, interdisciplinary tertiary training and leadership programmes at country or regional levels.198
Governance challenge 4: addressing power asymmetries in food systems
The expansion in the size, reach, and concentration of transnational food corporations and their massively increased, well-coordinated, political and economic power constitutes a major challenge to governance.181, 199
The large, powerful food and beverage corporations (Big Food) have used multiple strategies to obstruct obesity prevention. These strategies include adopting self-regulation to pre-empt and delay state regulation, public relations to portray industry as socially responsible, undermining and contesting the strength of scientific evidence, direct lobbying of government decision makers, and framing nutrition as a matter of individual responsibility (ie, norm promotion).181 Big Polluters, such as the large, powerful fossil fuel and cattle corporations, have used these same strategies to undermine strong government commitment and public support for action on climate change.200 Big Food’s obstructive power is enhanced in the context of hybrid governance arrangements that legitimise industry participation in public policy, and their financial resources and structural importance within national economies as suppliers of jobs and tax revenue. Furthermore, trade liberalisation, and with it greater international capital mobility, enables corporate actors to punish and reward governments for their regulatory decisions by relocating or threatening to relocate investments and jobs, or through threats of legal action under provisions for settlement in investor–state disputes in trade agreements.18, 181, 199
One strategy to address power asymmetries in the food system is to strengthen antitrust (ie, competition) laws to mitigate the economic and social harms of market concentration, and to define consumer welfare by something other than low prices.199 Another strategy is to more strongly anchor food and nutrition governance within rather than outside of government, alongside inclusive structures for meaningful civil society engagement and transparent processes for mitigating conflicts of interest related to private sector involvement.176, 201, 202 Strategies for strengthening the role of small-sized and medium-sized food system actors in governance is receiving increasing recognition. This trend is illustrated by the growth of urban food governance initiatives, including inclusive structures (eg, food policy councils) and local government ordinances (eg, planning regulations) that support for-profit and for-community food system activities by these actors at subnational levels.203
Next steps for strengthening governance
Strengthened governance systems at global, national, and local levels are urgently needed to address The Global Syndemic. Governing effectively will require coherence of action across several sectors and levels of society, credible and sustained commitment by the diversity of actors who govern, and the capacities and financial resources to govern. It will also demand actions that address the skewed distribution of power within the food and transportation systems that favour the status quo. The fragmentation of responsibility among large numbers of governance stakeholders with conflicting agendas and division of interests represents a further challenge that could be addressed through collaborative governance.
The slow and patchy progress to date in controlling The Global Syndemic, especially the obesity and climate change components, indicates the urgent need for a fundamental change in today’s governance systems. Arguably, the most important challenge is considering and redefining the fundamental goals of these systems. In this regard, the structures, practices, and beliefs that underpin capitalism in its present form (ie, extractive, materialist, and neoliberal) dominate the governance system. Political economy drivers that prioritise endless growth, by default, increase consumption to the point of detrimental overconsumption. Governance activities that simply tweak the parameters of this system (eg, pricing interventions, consumer information initiatives, and industry-led responses) are positive but will do little to address these deeper drivers. To do so, we must collectively ask who does our food system and economy ultimately serve, and for what purpose? How do we firmly place human and ecological health and wellbeing (ie, planetary health) as the central goal of governance systems going forward?204
Right to wellbeing
The 193 UN Member States have the power and the duty to address the drivers of The Global Syndemic.205 International human rights are a set of universal, indivisible, interdependent, and interrelated freedoms and entitlements created by international treaties and customary international law and enforced through national and international legal systems.
The Commission proposes that five interrelated human rights collectively constitute the right to wellbeing, an integrated framework that reflects the rights recognised by international law, including the right to health, the right to food, cultural rights, the rights of the child, and the implied right to a healthy environment (figure 4). The sections below describe Member States’ legal obligations to respect, protect, and fulfil each of these rights, and explores the implications of adopting the right to wellbeing framework to address The Global Syndemic.
The right to health
Many international and regional human rights treaties recognise the right to health. This right requires Member States to respect, protect, and fulfil rights to access both preventive health and health-care services.206 The former UN Special Rapporteur on the Right to Health has noted that Member States have a positive duty to regulate unhealthy food advertising and food companies’ promotion strategies.205 The right to health also involves addressing emerging social justice, food insecurity, water shortage, and climate change concerns.207 Human rights treaty-monitoring committees are now giving increased attention to obesity and related NCDs when examining Member States’ progress on implementing the right to health.208
The right to food
State obligations to realise the right to food are also anchored firmly in international law. The 1948 Universal Declaration of Human Rights (Article 25)210 and the 1966 International Covenant on Economic, Social, and Cultural Rights (ICESCR; Article 11) both recognise the right to food.211, 212 The ICESCR also links the right to food to other human rights such as the rights to health, work, education, and social security.213
The UN Committee on Economic, Social, and Cultural Rights, which monitors the implementation of the ICESCR, notes that State obligations include ensuring “access to the minimum essential food, which is nutritionally adequate and safe, to ensure freedom from hunger to everyone”.214 These obligations also include physical and economic access to adequate and culturally acceptable food at all times, produced and consumed sustainably to ensure access for future generations.215
In 2004, the FAO Member States adopted Voluntary Guidelines to support the progressive realisation of the right to adequate food in the context of national food security (Right to Food Guidelines).216 Member States pledged to ensure that changes in the availability of and access to food would not negatively affect peoples’ diet quality, and would support dietary diversity and healthy eating patterns, including the promotion of breastfeeding. The Rome Declaration on Nutrition, adopted at the Second International Conference on Nutrition in 2014, reaffirmed the right to adequate food and committed Member States to ending malnutrition in all its forms, noting the special needs of women and children.217 The Declaration noted that sustainable, equitable, accessible, resilient, and diverse food systems foster the progressive realisation of the right to adequate food. Achieving this right will also require that Member States enable women to have access to productive resources to support economic livelihoods.218 By early 2018, 30 countries had enacted legislation that explicitly recognised and protected their citizens’ right to adequate food.211
Cultural rights have been defined as “the rights of each person, individually and in community with others, as well as groups of people, to develop and express their humanity, their worldview and the meanings they assign to their existence and development through, inter alia, values, beliefs, convictions, languages, knowledge and the arts, institutions and ways of life”.219
Indigenous and tribal peoples who live in resource-limited regions of the world are disproportionately affected by The Global Syndemic.220 The globalisation of diets and urbanisation might have broadened choices for affluent people who live in LMICs. However, the resulting environmental degradation and reduction of dietary diversity has led to an increased risk of obesity and related NCDs among indigenous people and the urban and rural poor.221
The right to equality between women and men is equally relevant to addressing The Global Syndemic. The UN Convention on the Elimination of All Forms of Discrimination Against Women affirms the right of women and girls to participate in physical education, recreational activities, and sports without discrimination.221 However, in some contexts, these opportunities are limited to boys and men, and justified by reference to religious or cultural traditions. Moreover, certain cultural practices that restrict what women and girls wear can prevent them from engaging in physical activity.222
The Rights of the Child
The UN Convention on the Rights of the Child (UNCRC) contains obligations for Member States to provide “adequate nutritious food and clean drinking water” (Article 24(2)c).223 The Committee on the Rights of the Child, which monitors the implementation of the Convention, has commented that “Children’s exposure to ‘fast foods’ that are high224 in fat, sugar or salt, energy-dense and micronutrient-poor, and drinks containing high levels of caffeine or other potentially harmful substances should be limited”.223 To fulfil these obligations, Member States must also regulate the actions of non-state actors that undermine healthy food environments for children.
The right to healthy environments
Although the right to a healthy environment is more often recognised in domestic legislation and constitutions, it remains an emerging concept in international human rights law.224 This right is, in part, derived from the right to health: the ICESCR requires Member States to take steps that are “necessary for…the improvement of all aspects of environmental and industrial hygiene” (ICESR, article 12, paragraph 2(b)).214 The UN Committee on Economic, Social, and Cultural Rights has noted that “the right to health embraces a wide range of socioeconomic factors that promote conditions in which people can lead a healthy life, and extends to the underlying determinants of health, such as…a healthy environment”.215
Sustainability is an integral concept for the right to a healthy environment. The right to a healthy environment includes the right to environments that promote healthy food, active living, and active transportation and that permit physical activity at workplaces and educational institutes, including usable green spaces. This right also requires a system of food production and consumption that mitigates the health inequities and the effects of climate change that exacerbate food insecurity in LMICs.52
Implications of the right to wellbeing framework
The right to wellbeing framework provides a useful basis for addressing The Global Syndemic. Adopting the right to wellbeing framework has four implications.
First, international, regional, and national mechanisms for monitoring human rights can hold Member States accountable for achieving results in addressing key aspects of The Global Syndemic. These mechanisms can assess progress in the establishment of appropriate legislative, policy, and institutional frameworks (structural indicators), the delivery of resources (process indicators), and the achievement of results (outcome indicators).
Second, the right to wellbeing framework requires Member States to design and implement policies with the participation of all beneficiaries. Participation ensures that local agri nutrition contexts will be considered, that actions will be demand-driven, and that country-led actions will not be equated with government-led action. It also identifies alternative solutions based on local knowledge and conditions.
Third, the right to wellbeing framework requires Member States to adopt gender-sensitive, non-discriminatory interventions that include infants, children, the elderly, and pregnant or lactating women. It also includes poor communities, especially poor women, in all countries and increasingly the middle class in emerging economies. A right to wellbeing approach might be of particular value for population-wide interventions to ensure that they are equally effective in reaching vulnerable people.
Fourth, the right to wellbeing framework recommends that particular attention is given to the governance of the transition towards environments that actively support health and wellbeing. International human rights bodies insist that Member States should adopt long-term strategies that progressively work towards the realisation of rights.225
The Commission recommends that all stakeholders should promote the right to wellbeing framework as part of an expanded response to The Global Syndemic.
A Framework Convention on Food Systems
A global framework convention that sets out the agreed regulatory and policy framework for action to create healthier, more sustainable, and more equitable food systems would greatly enhance the implementation of national food policies to address The Global Syndemic. The WHO Framework Convention on Tobacco Control (FCTC) and the UNFCCC provide valuable models for a global approach to tackle the negative health and environmental effects of the food system because they are designed to address problems with multifaceted supply-side and demand-side drivers, and move beyond legal frameworks to provide specific policy guidance. Although food clearly differs from tobacco because it is a necessity to support human life, unhealthy food and beverage products (eg, energy-dense snacks, confectionary, and sugary drinks) are not a necessity. The commonalities of tobacco, unhealthy food and beverage commodities, and fossil fuels lie principally in the damage they induce and the behaviours of the corporations that profit from them. They also share common deep drivers and the need for a multifaceted policy response.226 Thus, a Framework Convention on Food Systems (FCFS) would strengthen the ability of nations to act, reduce the power asymmetries created by Big Food, and ensure comprehensive action in line with the double-duty or triple-duty actions needed to address The Global Syndemic. An FCFS would include policy actions to strengthen food systems for health and social equity, sustainability and prosperity. It would also strengthen the right to wellbeing and accountability systems for action.227 Linking the powerful and diverse stakeholders around food systems into a common framework makes sound strategic sense. Such a strategy would enable national governments to strengthen the public health, social equity, and environmental protection purposes of food systems in relation to the current dominant commercial purpose. Many countries have been unable to achieve this goal because of the vested interest influence of transnational corporations and the trade agreements that reinforce this power imbalance.36, 88, 119
Hoffman and colleagues228 proposed a set of four criteria to assess the value of developing a framework convention as an international policy instrument for a global health issue. The Commission believes that an FCFS would meet these criteria (appendix p 34). A two-step process is needed to develop a global treaty for food systems based on the FCTC model. First, an international agreement to address conflicts of interest must be instigated. The agreement could be based on Article 5.3 of the FCTC,229 which explicitly excluded the tobacco industry from policy development and implementation. An article as strong as Article 5.3 must be adapted to tackle unhealthy food systems because the current principal attempt to address conflicts of interest, WHO’s Framework for Engagement of Non-State Actors,230 does not fully protect WHO and Member States.231
Three principles characterise the identification and management of conflicts of interest: (1) a fundamental and irreconcilable conflict exists between some food and drink industries’ interests and those of public health and the environment; (2) parties, when dealing with these industries or those working to further their interests, should be transparent and accountable; and (3) no fiscal advantages or inducements to produce food and beverage products that damage human and environmental health should exist.
There is extensive backing for a Framework Convention approach to food and obesity among civil society organisations.232 More than 200 local, national, and international organisations and experts wrote letters of support to the Directors General of WHO and FAO before the Second International Conference on Nutrition in 2014.233 Additionally, the Pan American Health Organization’s application of law to public health234, 235 can be used to showcase what works at the regional level to guide the development of a global treaty.
Global to local implementation
Effective governance will be essential in addressing The Global Syndemic. Orienting governmental efforts to address the Syndemic effectively will require changing the food, transportation, land-use, and urban-design systems that contribute to The Global Syndemic by addressing their deep drivers. The syndemic concept provides a unifying frame that could unite constituencies that are currently distinct.
As we have indicated, multiple recommendations from WHO have targeted undernutrition and obesity separately, although their uptake and implementation have been patchy. However, strategies at the national level could include government action on their national commitments to the Decade of Action on Nutrition or support for an FCFS. The World Trade Organization could support WHO’s international standards and recommendations for food labelling and food marketing to children, to prevent each country having to defend legal challenges on the basis of restriction of trade and investment. The World Bank and other development agencies could provide technical assistance to countries to implement double-duty or triple-duty actions that address the Global Syndemic.
The recent withdrawal of the USA from efforts to limit greenhouse-gas emissions demonstrates the fragility of agreements that might change based on the politics of the countries involved. These observations suggest that effective strategies to address The Global Syndemic at the global level will be unlikely to succeed without a broader base of support. As with other social movements, such as for tobacco control and sugary drinks taxes, efforts to address The Global Syndemic are more likely to begin at the community, city, or state level, and subsequently build to a national or global level. For example, despite the Trump administration’s decision to withdraw from the Paris Agreement on climate change, 2700 leaders from US cities, states, and businesses representing 159 million people and $6·2 trillion in GDP have continued efforts to mitigate greenhouse-gas emissions.236
Linking those stakeholders working separately in obesity, undernutrition, and climate change is one of the major challenges to creating concerted local to global actions. Implementation at all levels will require the identification of actions common to two or more groups. By collaborating on creating double-duty or triple-duty actions, these stakeholders could start uniting and collectively giving greater impetus to achieving success for The Global Syndemic. A second challenge is how actions are framed. For example, in many LMICs, obesity in children might be considered a sign of health and a sign of wealth or status in adults. Other framing focused on the consequences and costs of diabetes might be more persuasive than a focus on obesity. Third, growth of social movements for systems change will require grass roots engagement around local solutions that engage people, such as reduced meat consumption, support for and use of active transportation systems, or zoning regulations for land use and urban design that are eco-friendly and promote equity.