The World Health Organization has been caught up in a real mess by trying to categorize and create hurdles for collaboration with the growing number of non-State actors that are active in public health matters related to the mission of the WHO. The complexity of this mess was in the spotlight at the recent WHO Executive Board, meeting from 23 to 27 January 2018. Several agenda items touched on the issue, including ongoing attention to addressing the challenges of non-communicable diseases for healthy lifestyles. More knotty agenda items, however, had to do more directly with WHO’s relations with non-State actors – both its new but yet to be implemented basic Framework of Engagement with Non-State Actors (FENSA) generally and its guidelines for managing conflict of interest in the nutrition world more specifically. The outcome of the deliberations on these agenda items is rather encouraging, and we hope that the new Director-General will actually clean up the mess.
The FENSA Context
Putting this into context, we note that the lengthy and contentious deliberations on FENSA over the past several years were understandably triggered by the increasing number and variety of non-State actors in global public health circles. It is to be commended that the WHO effort was driven by a search for ways to accommodate this broadening array of actors.
Regrettably, however, the WHO has also had to contend with a wall of resistance to change, especially about engaging with any of these non-State actors that might be associated in any way with commercial interests. The WHO ultimately produced a clumsy Framework of Engagement for Non-State Actors (FENSA) that seeks to prescribe elaborate “due diligence” for scrutinizing each non-State actor that might want to engage with the WHO and then even more cumbersome procedures for assessing risks based primarily on whether the entity has any “commercial interests” or not. Although there is token recognition of conflicts of interest that are not just financial in nature, the emphasis has been on assuming collaboration is risky in general and that collaboration has to be especially protected against commercial interests – i.e. that commercial interests are inherently in conflict with public health interests.
Guidelines for Conflict of Interest in Nutrition Policies and Programmes: the EB Debate
Before commenting on the latest debate regarding FENSA implementation, however, we also note that the proposed guidelines from the WHO for countries to use in determining which non-State actors might have a conflict of interest with public health nutrition policies and programmes have gone even further into the quagmire of complexity. The mandate for this separate but related initiative also came from the World Health Assembly, and it was just prior to the meeting of the January 2018 Executive Board that a revised version of these guidelines was published. It is in the nutrition area that the resistance to engagement with the private sector has been especially strong. As a result, there is an even more elaborate six-step process in the proposed guidelines for scrutinizing the alignment of any non-State actor with the public health interest on nutrition.
The debate on this package at the Executive Board in January 2018 was technically not supposed to elicit any formal decision (since guidance documents are voluntary and expert driven). But there were criticisms, nonetheless. Several Board members, mostly developed country representatives, cited the merits of a simpler alternative, such as the ten principles used by the Scaling Up Nutrition (SUN) Movement, and urged further consultations. Others, however, and mostly from developing countries, expressed a readiness to pilot-test the tool.
This is, in any case, what the WHO Secretariat has proposed, and it will be interesting to see if there are any other consultations, including perhaps a more detailed comparison with the SUN Movement’s approach. Of course, one of the issues here is that the WHO proposed guidelines specifically discourage multi-stakeholder platforms like the SUN Movement. But again, there was no decision point on this agenda item. So the main outcome of the debate was a display of discord about the usefulness of the proposed guidelines. Our own recommendation would be for at least one if not all of the pilot studies to include a comparison with the SUN Movement’s principles – and its reference note and toolkit.
FENSA Implementation: the EB Debate
The 2018 Executive Board, however, also debated FENSA implementation, which has proceeded more slowly (by more than a year) than envisioned when the WHA finally endorsed it in May 2016. The implementation tools were supposed to be in place by May 2017, including a guide for staff, a handbook for non-State actors, and a fully operational Public Register of Non-State Actors. The guide for staff did appear finally just before this January 2018 session of the Executive Board, but the register is still in a pilot stage, and there is still no handbook for non-State actors.
The debate itself was fairly limited – mostly encouraging the WHO to put the implementation tools in place. There were a few representatives who asked for more feedback from non-State actors on whether the process is working, and whether the process is too bureaucratic or too long. No non-State actors, however, were prepared to respond to this request (which came at the end of the final evening session of the Board when many observers had already left). In any case, it would probably be more informative to seek feedback from the non-State actors who are holding back from affiliation with the WHO – many of them because of the complexities for multi-stakeholder associations.
Looking to the Future
At the end of the FENSA debate, we learned that a FENSA steering group has now been set up to address questions of transparency and due accountability of the various categories of non-State actors. The Assistant Director-General Michele Boccoz in charge of External Relations also informed the Board that questions regarding conflict of interest have been deferred to the Legal Counsel, where they clearly belong since COI is a very technical legal issue.
Also at the end of the FENSA debate, the Director-General himself spoke up. This proved to be very informative. Not surprisingly, the new Director-General has had a thing or two to say about the matter, and this may be the main reason it has slowed down. One issue that had not yet been covered, he said, was the management of risk. He went on to say that the WHO can’t avoid taking risks but can manage it – AND that the WHO has been too risk averse. This is keeping the WHO from moving forward, he said.
Dr. Tedros elaborated on his belief that engagement with the food and beverage industry, as he encouraged at the recent Montevideo Conference on Non-Communicable Diseases in October 2017, is “not a problem”. This clearly relates the FENSA debate to the one on the guidelines for COI with industry in nutrition. “We don’t believe in disengaging, and we have nothing to hide,” he said. “We have the facts and the science.” Engagement, he continued, does not mean we won’t enforce the law. Through engagement, he argued, we can disagree and know them (the industry) more and identify areas of cooperation and where to take measures for regulatory enforcement.
So now the targeted deadline for full implementation of FENSA is the May 2018 WHA, although the Ms. Boccoz acknowledged in her closing remarks that it may take longer for the “new IT tool” to be fully ready. “We want something”, she said, “that works for all users”. One can certainly appreciate the message of a new direction on this issue coming from the Director-General.
One can also hope that the work we did through the Global Social Observatory on assisting the SUN Movement with a reference note and toolkit on an inclusive multi-stakeholder framework for the prevention and management of conflict of interest in nutrition will contribute to a more inclusive approach at the WHO, both within FENSA and within the proposed guidelines for COI in nutrition. The timeline for this latter initiative does extend beyond May, since it will probably take at least the rest of 2018 to do the pilot studies. We wish the WHO well in adapting its new tools to a useful and manageable inclusiveness