Philanthropic partnerships

Philanthropic partnerships involve limited engagement, reciprocity and activities that are peripherally important to each partner's mission. A philanthropic partnership occurs when a company gives a charitable financial or food donation to an NGO either through an anonymous or acknowledged donation accompanied by media coverage for each partner^(51, Reference Thomas and Fritz^{59, 68, 69)}.

Transactional partnerships

Transactional partnerships build mutually beneficial relationships to advance each partner's agenda through compatibility among organizational values, missions and goals⁽Reference Austin²⁶⁾. These partnerships involve higher levels of interaction and resource investments compared with philanthropic partnerships. Table 1 defines terms (i.e. contributions-in-kind, co-branded sponsorships and cause marketing)^(70–72) that are revenue-raising instruments used by NGO to implement programmes. While transactional partnerships may enhance a company's brand reputation, they can adversely affect an NGO's reputation⁽Reference Neuman^43, Reference Shields^44, Reference Thomas and Fritz⁵⁹⁾. Examples of transactional partnerships⁽Reference Freedhoff and Hébert^{39, 73–82)} are provided in Tables 2 and 3.

Transformational partnerships

Transformational partnerships involve the highest level of engagement, resource investment, managerial complexity and relationships built over time to mutually influence the institutional cultures and practices of each partner. Transformational partnerships involve many partners to stimulate large-scale social or policy changes⁽Reference McLachlan and Garrett¹⁾ to address the double burden of malnutrition (Fig. 1). Examples of aspiring transformational partnerships^{(54–56, 83, 84)} are discussed below and in Tables 2 and 3. Thereafter, we present certain conceptual, practical and ethical challenges.

Maternal and child health integrated programmes to address undernutrition

In 2008, the US government funded the Maternal Child Health Integrated Program (MCHIP) to accelerate progress towards MDG 4 (reduce infant and child mortality) and MDG 5 (improve maternal health) in thirty priority countries⁽⁵⁷⁾. MCHIP uses partnerships with governments and NGO to implement programmes at scale to improve maternal and child nutrition and health^{(57, 85)}. In 2011, a global PPP, Saving Lives at Birth, was launched by the US government, private funders, Grand Challenges Canada and the World Bank⁽⁸⁶⁾.

Evaluations of child survival programmes suggest that countries achieve the greatest impact by developing strategic PPP supporting mutual programme objectives; responding to each country's specific cultural factors; leveraging each partner's technical expertise and resources to meet clear objectives; and implementing high-impact interventions through scaled-up programmes for broad population coverage⁽⁵⁷⁾.

Global Alliance for Improved Nutrition to address micronutrient deficiencies

Global Alliance for Improved Nutrition (GAIN) is an international alliance that addresses poor health and malnutrition among vulnerable groups by improving their diet quality^{(55, 56)}. GAIN is the major convening vehicle for governments, international NGO and private-sector stakeholders to promote food fortification. GAIN reports ‘scaling up 36 large collaborations in 25 countries since 2002 to reach 400 million people with nutritionally enhanced products’⁽⁸⁷⁾. GAIN aspires to mobilize $US 700 million of private-sector investment through a Business Alliance^{(55, 56)}. GAIN supports partnerships with global food and beverage companies to stimulate market-based solutions that address malnutrition, produce commercial benefits for companies, and encourage economic development in low- and middle-income countries^{(55, 56, 87)}.

Evaluations of food fortification programmes in low-income countries suggest that cost-effective and sustainable results are feasible when there is close collaboration among the public sector to improve population health; the private sector, with expertise in food production, technology, marketing communications and consumer reach; and NGO that deliver programmes and services to vulnerable groups⁽Reference Mannar and van Ameringen⁸⁸⁾. Independent evaluations of GAIN's Business Alliance are needed to understand the benefits and challenges of using a PPP approach to address micronutrient malnutrition.

International Food & Beverage Alliance and the Healthy Weight Commitment Foundation to prevent obesity

The WHO Global Strategies^{(31, 58)} acknowledge that private-sector partners should play a central role in promoting healthy food and eating environments to prevent NCD. In 2008, eight leading food and beverage companies founded the International Food & Beverage Alliance (IFBA) in response to rising obesity rates⁽⁸³⁾. In 2009, ten IFBA members with a combined annual revenues of $US 350 billion⁽Reference Yach, Khan and Bradley³⁵⁾ shared a report with WHO⁽⁸⁹⁾, suggesting progress had been made to: (i) reformulate and develop new products to improve diets; (ii) provide clear nutrition information to consumers; (iii) extend responsible advertising and marketing pledges to children globally; (iv) raise awareness about balanced diets and increasing physical activity; and (v) support partnerships to promote healthy lifestyles. Independent evaluations have not confirmed IFBA's self-reported progress.

In 2009, the Healthy Weight Commitment Foundation (HWCF) was formed in response to the US obesity epidemic as an industry coalition comprised of food, beverage and food retail companies that partners with business-interest NGO (i.e. industry trade associations) and public-interest NGO. The HWCF partners have pledged to make measureable changes to reformulate and expand healthier products in the marketplace, to support worksite wellness, and to promote energy balance education to children in schools^{(84, 90)}. In 2010, the HWCF members partnered with private foundations and government through First Lady Michelle Obama's Lets Move! obesity prevention campaign⁽⁹¹⁾. An independent evaluation is underway by academic groups, funded by the Robert Wood Johnson Foundation, to assess the coalition's progress in making changes in the three settings.

Balancing commercial and public health interests

Collaborative partnerships provide companies with commercial advantages, yet private commercial interests often conflict with public interests⁽Reference Stuckler, Basu and McKee⁹²⁾ and balancing win–loss outcomes is tough. A win–win outcome may be possible to address global food insecurity^{(32, 52)}; develop inexpensive and high-quality commercial, complementary food products and integrated marketing communications campaigns that address young child undernutrition in emerging markets⁽Reference Engle and Huffman^10, Reference Wojcicki and Heyman^33, Reference Singh, Daar and Singer⁹³⁾; drive product innovation for new consumers⁽Reference Traitler, Watzke and Saguy⁶⁶⁾; build community disaster resilience⁽⁵³⁾; improve the systematic delivery of humanitarian assistance⁽Reference Thomas and Fritz⁵⁹⁾; and provide comprehensive integrated packages of nutrition interventions to reach malnourished populations during complex emergencies⁽Reference Webb⁶⁰⁾. However, even these partnerships can have unintended consequences and not produce benefits for every partner or target population⁽Reference Richter^29, Reference Monteiro, Gomes and Cannon³⁶⁾. It is arguable whether markets can deliver both short-term financial returns for companies and long-term social, economic and health benefits to address the spectrum of global malnutrition challenges⁽Reference Richter²⁹⁾.

Current agribusiness-sector models are more compatible with producing and distributing food as a response to hunger and food insecurity than reducing portion sizes or substantially reformulating food and beverage products to improve diet quality and prevent overconsumption⁽Reference Kraak, Kumanyika and Story⁹⁴⁾. Concerns relate to any marketing strategy that may increase consumers’ brand loyalty for a company's unhealthy branded product line⁽Reference Kraak, Kumanyika and Story⁹⁴⁾ such as promoting bottled water or fortified products that influence the purchase and consumption of branded sugar-sweetened beverages or energy-dense snacks⁽Reference Monteiro, Gomes and Cannon⁴⁰⁾. These are relevant concerns for consumers with limited discretionary household incomes, who are vulnerable to persuasive marketing practices and are disproportionately affected by obesity and NCD in emerging markets⁽Reference Monteiro, Gomes and Cannon^36, Reference Monteiro, Gomes and Cannon^40, Reference Taylor, Satija and Khurana⁹⁵⁾. Risks arise when NGO facilitate companies’ access to consumers and influential groups and when partners fail to monitor and evaluate partnership processes and outcomes.

PPP are influenced by global and national government structures. The Codex Alimentarius Commission uses international standards and strong intergovernmental oversight to protect consumer health by promoting global food safety and ensuring fair food trade practices⁽Reference Somogyi, Hathcock and Biesalski⁹⁶⁾. Global PPP may identify advantages within the regulatory environment to enhance outcomes, such as providing standards to foster a competitive environment to move industry practices and entire food or beverage product portfolios towards desirable targets to achieve population health benefits⁽Reference Monteiro, Gomes and Cannon^36, Reference Richter⁹⁷⁾. Examples include the World Action on Salt & Health, a voluntary global initiative that engages governments, industry and NGO to implement strategies to reduce the salt content of processed foods and Na consumption in populations⁽⁹⁸⁾; and the Flour Fortification Initiative⁽Reference Maberly, Grummer-Strawn and Jefferds⁹⁹⁾, an international network of public and private organizations in the specific context of it encouraging government-regulated and voluntary quality-control systems for Fe fortification of wheat flour to benefit populations in certain countries⁽Reference Johnson and Wesley¹⁰⁰⁾.

Partners must develop mutual trust and open communication to assess where profit-driven activities and public health benefits overlap or conflict. NGO and private-sector companies could dedicate staff and sufficient resources to nurture and sustain partnerships that balance social and health investments with business profits⁽Reference Austin²⁶⁾. Partners must also anticipate unintended consequences and collaborate to improve the nutrition and health outcomes of targeted populations.

Managing conflicts of interest and biases

NGO and partnering food, beverage and restaurant companies should seek to effectively manage conflicts of interest and biases to establish trustworthy relationships, allay public concerns about compromised partner integrity, reduce the risks to each partner's reputation and minimize unintended consequences for programmes or targeted populations.

Conflicts of interest may arise when NGO staff receive personal gifts or in-kind resources from companies to influence decision making, research or public positions⁽Reference Stuckler, Basu and McKee^92, Reference Brody^101–Reference Brennan, Rothman and Blank¹⁰⁴⁾. Further, it is arguable that NGO may be susceptible to ‘white hat bias’⁽Reference Cope and Allison¹⁰⁵⁾, a tendency to disregard facts and distort the truth to serve righteous ends.

Private-sector partners face challenges arising from managing self-dealing conflict of interest. A company's commercial activities may benefit from research generated through a partnership funded by the company's foundation, which may be legally required to act at arms length. Public trust and credibility may be diminished due to the apparent duplicity of private foundations' investments. For example, the Bill & Melinda Gates Foundation has generously supported programmes targeting global health and undernutrition. At the same time, the Foundation has generated a portion of its wealth through direct investments in companies that produce and market products linked to rising obesity and NCD rates, including McDonald's Corporation and The Coca-Cola Company, and indirect investments in Coca-Cola, Kraft Foods and Nestlé through Berkshire Hathaway⁽Reference Stuckler, Basu and McKee⁹²⁾.

These considerations do not necessarily preclude PPP but should rather be viewed as opportunities to be addressed to strengthen partnerships. Private-sector partners would be better able to address conflicts of interest by disclosing and improving their accountability for labour, environmental and health-related policies, practices and performance. NGO must be able to independently criticize a private-sector entity for issues unrelated to the partnership to fulfil an important watchdog function to hold governments and industry accountable for public health commitments by exposing non-compliance and inaction^(24, Reference Richter²⁹⁾.

Guidelines have been proposed to minimize conflicts of interest and biases related to industry-sponsored research with commercial applications⁽Reference Rowe, Alexander and Clydesdale¹⁰³⁾. Organizations could make partnership terms, outcomes and benefits more transparent and explicit through clearly written contracts; incorporate guidelines for managing conflicts of interest into governing bodies’ bylaws; and widely promote written policies and an institutionalized process to standardize expectations for employees to disclose financial and non-financial industry relationships⁽Reference Stuckler, Basu and McKee^92, Reference Brody^101, Reference Brennan, Rothman and Blank¹⁰⁴⁾.

Public health professionals and NGO staff who receive industry funding could reject payment or withdraw from institutional decision making⁽Reference Stuckler, Basu and McKee^92, Reference Brody¹⁰¹⁾, decline to give industry-sponsored presentations, avoid ghost-writing publications, and turn down consulting arrangements unless governed by clearly written contracts⁽Reference Brennan, Rothman and Blank^{104, 106)}.

Using co-branded activities to support healthy products and healthful diets

Co-branding is apparent in all types of partnerships. NGO should develop criteria and systems for accepting company donations and contributions in-kind that are appropriate to their mission, adhere to standard healthy nutritional guidelines, support local sustainable markets and food systems, align with desirable items distributed through their programmes, and require minimal handling or transportation costs⁽Reference Thomas and Fritz^{59, 72)}.

NGO may be attracted by food and beverage company sponsorship and cause marketing to secure unrestricted funds to support professional societies and conferences⁽Reference Oshaug^42, Reference Brody^101, Reference Tobin, Dwyer and Gussow¹⁰⁷⁾, nutrition research⁽Reference Rowe, Alexander and Clydesdale^103, Reference Nestle¹⁰⁸⁾, programmes⁽Reference James¹⁰⁹⁾ and sporting events⁽Reference Danylchuk and MacIntosh¹¹⁰⁾. Sponsorship is a commercial activity to promote a company's brand, not a philanthropic gift^(70, Reference Rundall⁷¹⁾. Risks arise when partners either fail to effectively manage conflicts of interest or engage in duplicitous activities such as concurrent lobbying of legislators to support issues that undermine public health goals⁽Reference Spolar and Eaton^{111, 112)}.

One approach to facilitate decision making about co-sponsoring events is to appoint a brand advisory committee to use a risk-assessment framework with specific criteria to assess the brand, nutrient and event profiles; company marketing and distribution practices; and contextual relevance⁽¹¹³⁾. Obtaining accurate proprietary information about a company's marketing and distribution practices is an ongoing challenge.

Public perceptions about global food, beverage and restaurant company sponsorship favour branded products that have healthy nutritional profiles compared with products with less healthy profiles (i.e. hamburgers, pizza, chocolate bars, salty snacks and sweetened beverages)⁽Reference Danylchuk and MacIntosh¹¹⁰⁾. NGO and other partners could develop clear criteria about co-sponsored arrangements and align all integrated marketing communications with sponsored products or events to consistently promote public health goals⁽Reference Danylchuk and MacIntosh¹¹⁰⁾.

Complying with ethical codes of conduct

Codes of conduct raise and maintain public awareness about specific issues, build public pressure to change practices that are detrimental to society, and encourage debate about appropriate standards for corporate conduct⁽¹¹⁴⁾. Most global food and beverage companies have generally complied with legally binding treaties, such as the UN Convention on the Rights of the Child⁽¹¹⁵⁾; and voluntary codes of conduct, such as industry self-regulatory programmes to advertise or market responsibly to children⁽Reference Kolish, Enright and Burke¹¹⁶⁾ and the International Code of Marketing of Breast-Milk Substitutes⁽¹¹⁷⁾. In the latter case, there are notable exceptions documented by independent groups when certain companies’ marketing practices continuously violate the Code⁽Reference Aguayo, Ross and Kanon^118–120) while industry-supported, third-party verification mechanisms confirm company compliance^{(121, 122)}. These issues cause tension, erode public trust and respect for partners, and diminish the effect of voluntary codes.

Several company pledges have been deemed inadequate to protect children's health and well-being. Many companies’ current marketing practices promote unhealthy products that undermine children's right to a healthful diet⁽¹¹⁵⁾. Independent evaluations⁽Reference Lang, Rayner and Kaelin^123–Reference Hawkes and Harris¹²⁷⁾ have documented questionable marketing practices of global companies participating in GAIN, IFBA and HWCF (Table 3) that have not yet been adequately addressed by industry self-regulatory programmes or individual companies, or dealt with in a coordinated way among public-interest NGO. Companies have used their own nutrition guidelines for product reformulation and varied nutrition standards to define healthy products; applied more lenient nutrition criteria for products they manufacture; varied self-regulatory marketing pledges between countries and regions; lacked clear policies on marketing to children and adolescents; excluded packaging, point-of-sale materials, in-school marketing, contributions in-kind and new media from pledges; and made no commitments to stop marketing unhealthy products to children through their parents.

Table 3 Profiles of transnational food, beverage and restaurant companies that use public–private partnerships to address global nutrition challenges (adapted from references 56, 83–84, 87, 89, 90, 134–148)

GAIN, Global Alliance for Improved Nutrition; IFBA, International Food & Beverage Alliance; HWCF, Healthy Weight Commitment Foundation.

*Estimated annual revenue represents income that a company receives from its normal business activities from the sale of goods and services to customers. Revenue figures are derived from each company's annual or corporate social responsibility report and/or website.

Shared principles have been proposed for stakeholders to promote infant and young child nutrition⁽Reference Singh, Daar and Singer⁹³⁾ and reduce the commercial promotion of unhealthy products to children and adolescents⁽Reference Swinburn, Sacks and Lobstein¹²⁸⁾. Industry self-regulatory programmes are likely to be effective when they establish and widely promote transparent regulatory standards with input from diverse stakeholders, develop meaningful objectives and benchmarks, institute a mandatory public reporting mechanism to show compliance with voluntary codes, and allow evaluations to be conducted by independent groups⁽Reference Sharma, Teret and Brownell¹²⁹⁾. The timing is crucial for all stakeholders to implement, monitor and evaluate these principles given WHO's global resolution recommending that Member States substantially reduce marketing practices that promote unhealthy food and non-alcoholic beverage products to children and adolescents⁽¹³⁰⁾.

Conducting due diligence to assess partnership compatibility and evaluate outcomes

Frameworks and tools are available, including compatibility assessment criteria (Table 4) and a benefit–risk decision-making pathway (Fig. 2), to help NGO conduct due diligence to select appropriate partnerships for collaborations that promote synergy, transparent decision making and accountability for specific outcomes⁽Reference Kraak and Story^{27, 62,} Reference Lasker, Weiss and Miller^{67, 131–133)}.

Table 4 A tool to assess partnership compatibility between non-governmental organizations (NGO) and transnational food, beverage and restaurant companies to address global nutrition challenges (adapted from reference 27)

Fig. 2 (colour online) A benefit–risk decision-making pathway* for non-governmental organizations (NGO) to engage with transnational food, beverage and restaurant companies through public–private partnerships (PPP) to address the global double burden of malnutrition. *For an NGO to put this decision-making pathway into practice, steps 1–5 are non-negotiable and all need to be ‘yes’ before proceeding with a potential PPP. Step 6 is the ongoing and final decision making required to ensure that the PPP will optimize benefits and minimize risks to all partners and target populations (adapted from WHO (2010)⁽¹⁸⁾, VicHealth (2008)⁽⁶²⁾, Partnership Governance and Accountability Initiative (2010)⁽¹³²⁾ and Parramatta City Council (2006)⁽¹³³⁾)

NGO may already have developed corporate social responsibility profiling, partnership criteria and institutionalized guidelines governing how they partner with companies that manufacture socially unacceptable products (i.e. weapons, tobacco) or engage in egregious practices (i.e. child exploitation, gambling and extractive mining). NGO should also develop partnership profiling, guidelines and criteria to evaluate the totality of partnership activities with transnational food, beverage and restaurant companies, including their compliance with voluntary codes^(131–133) and ensure that PPP are harmonized with country strategies, institutions and processes.