Overview of consultation responses
We collected 784 responses related to 15 consultations. The responses to the remaining 25 consultations were not publicly available. We obtained an additional 420 responses to one consultation from the WHO. Of the collected 1,204 consultation responses, 181 contained at least one of the search terms. Of those 21 were excluded as duplicates and 25 were excluded as only descriptive. 135 (11.2%) were included in the analysis. These stemmed from 10 consultations that took place in 2017 (N = 22), 2018 (N = 1), 2020 (N = 52), 2021 (N = 32), 2022 (N = 24) and 2023 (N = 4). Supplementary file 2 presents an overview of the included consultations, where they were obtained and the number of responses that were included in this study. The majority of responses including in our analysis were from NGOs (N = 59, 43.7%), followed by trade associations (N = 37, 27.4%), national governments (N = 14, 10.4%) and multi-stakeholder platforms (N = 11, 8.1%).
Terminology used to discuss multistakeholder governance
The mostly commonly used term(s) were ‘multistakeholder*‘ or ‘multi-stakeholder*‘ (25.7% of total number of terms used), ‘multisector*’ or ‘multi-sector*’ (23.9%), ‘all stakeholders’ or ‘all relevant stakeholders’ (15.5%) and ‘public private partnership*’ or ‘ppp*‘ (14.4%) (See Table 2).
Justifications for and against a multistakeholder approach
A wide range of arguments were used for and against MSG which could be mapped to all categories in the typology (Table 1). Most arguments centred around the in- or exclusion of industry actors in MSG, and the democratic, technocratic and fairness considerations associated with this. Table 3 provides an overview of the key arguments used for and against MSG in each of the topic areas covered above.
In the following, we present key findings by each of the domains outlined in Table 1.
Arguments centred around democratic procedure and performance
Participation was the most common justification for adopting a multistakeholder approach, mentioned in 61.5% of the responses. However, there were significant differences in who respondents argued should participate in MS initiatives: NGO and academic organisations often explicitly excluded the private sector. For example, an NGO noted that “the benefits of multisectoral approaches to alcohol harm are substantial” while later emphasising that
we must highlight that all stakeholders in WHO GAS [Global Action Strategy] are not equal […] the alcohol industry should not be placed in equal standing with international partners and civil society as the current working document does. The alcohol industry is the single biggest obstacle to WHO GAS implementation around the world. (NGO)
In contrast, industry-affiliated respondents repeatedly and explicitly emphasised private sector inclusion, with one trade association, for example, noting that “We believe that partnership working is fundamental to reducing harmful drinking and must include all relevant stakeholders, including the industry”. However, those advocating in favour of multistakeholder or multisectoral governance often failed to – or purposefully did not – clarify which ‘stakeholders’ or ‘sectors’ they referred to.
Arguments related to accountability of multistakeholder processes featured in 25.2% of consultation responses, though generally not by those critical of MSG. Many of those in favour of multistakeholder action recognised the need for accountability and mostly suggested transparency mechanisms or relying on trust relationships. As one government respondent suggested,
COI mitigation and management tools, such as Codes of Conduct, can be used to increase transparency and reduce risk around actual COIs while promote successful multi-stakeholder partnerships. Codes of Conduct, non-binding sets of principles for engagement among stakeholders, promote transparency and accountability. (national government)
This was similarly expressed by many industry-affiliated actors, suggesting that “disclosure plus transparency can be the main tools to limit influence not aligned to mission.” (consultant).
While arguments around democratic performance were not common, used in 7.4% of responses, almost identical arguments related to this were utilised both as arguments for and against MSG. One industry-affiliated respondent argued that “Unjustifiably restricting engagement with the private sector would not only be antithetical to democracy and good governance, it would also deprive member states of the knowledge, expertise and resource of the private sector” (trade association). At the same time, some respondents opposing MSG used very similar arguments, noting “the risks that this [multistakeholder governance] model brings to […] democratic policy processes” and arguing that MSG had “CoI [conflicts of interest] intrinsically built in and erodes decision-making in public interest [sic]” (NGO). WHO’s engagement in multistakeholder partnerships to date, for example the WHO Global Coordination Mechanism, was seen to further legitimise the multistakeholder governance approach, as it “possess[es] ‘normative’ impact and value and hence provide[s] non-state actors with further global legitimacy” (NGO).
Arguments centred around technocratic procedure and performance
Arguments of procedural efficiency and technical expertise were used in 27.4% and 30.4% of responses respectively, being particularly highly prevalent in the responses from industry-affiliated actors, especially when justifying the inclusion of private sector actors. Industry’s ‘resources’ and ‘expertise’ were argued to be crucial not only for the success of the policy response in question, but also that of the WHO itself. For example, one trade association stated that
By seeking greater input, not less, global institutions can best aid in the development of strong, sustainable and widely supported outcomes that are built on a science- and evidence-based approach. Efforts to restrict the ability of member states to engage with stakeholders, particularly in the private sector, groups [sic] can only result in weaker policy outcomes and undermine the credibility of not only the final policy recommendations but also the institutions that recommend them. (Trade association)
The emphasis was placed especially on industry’s ‘technical expertise’ and the necessity for drawing on this expertise to enable specific policy options:
During the policy development process, the role of the private sector in helping to inform science-based policy development and assisting in implementation, drawing on our breadth of technical expertise (e.g., in product reformulation) to help people everywhere achieve and maintain healthy diets (Trade association).
Notably, the specific policy options that these respondents suggested for multistakeholder working predominantly focused on ‘problematic consumption’, ‘product reformulation’ and ‘behaviour change’ and they mostly advocated for technological ‘fixes’ to public health problems. A trade association in the alcohol sector for example noted that it has “committed itself to a variety of actions to stimulate responsible drinking” and that they “work together with all other stakeholders to promote responsible alcohol consumption”. Similarly, different trade associations in the food industry noted the private sector’s “breadth of technical expertise (e.g., in product reformulation) to help people everywhere achieve and maintain healthy diets”, as well as the “essential need for multi-stakeholder partnerships […] to drive the reduction of nutrients of public health concern in the food supply or to drive change in consumer habits”. An academic, who was critical of industry involvement in MSG, was the only respondent who explicitly included a warning to WHO regarding this approach, stating that:
there are risks that conflicts of interest will compromise objectives and values of nations other than their public health goals […] The manufacturer wants the government to address the nutritional problem with an approach that would rely on using the manufacturer’s products. The government program, on the other hand, can meet its nutritional goals in multiple ways and might well achieve a better result using an approach that was not in the interest of the manufacturer. (Academic)
Aside from the suggested benefits of industry inclusion for the quality of policy solutions, respondents in favour of MSG also referred to enhanced efficiency and cost-effectiveness of the policy process. For example, one trade association noted that multistakeholder approaches were necessary to allow them to “join WHO in our willingness to promote evidence-based and cost-effective interventions.” (Trade association). In response to WHO’s development of a conflict of interest tool, many respondents in favour of MSG argued that such a mechanism would limit the efficiency of the policy process, stating that “Use of the tool in its entirety would require exceptional amounts of time and attention, which would both misuse limited resources and slow or effectively freeze the process of partnership” (trade association).
Conversely, many NGOs and academic organisations warned against MSG as leading to less effective policy due to the risk of industry influencing the policy-making process, citing the industry’s “record of undermining effective policy development” (Academic), leading “government resolve to bring in effective legislation [to] be undermined and global and national policy agendas subverted” (NGO). This was directly linked to the MSG model, further noting that the industry “bring[s] into play the powerfully promoted MSI and PPP model to position themselves as responsible ‘corporate citizens’ who should be seen as ‘a part of the solution’ – not a party to be regulated” (NGO). Some of those in favour of multistakeholder approaches invoked partnerships they have had in the past as justifications of the problem solving ability of multistakeholderism, which was referred to in 34.8% of responses. Predominantly industry-affiliated respondents provided a list of ongoing or completed multistakeholder partnerships they themselves had been a part of to justify their advocating for multistakeholder approaches, though often without presenting evidence on their effectiveness from independent evaluations, only stating, for example, that “these [collaborative] efforts have been a fundamental component of national government efforts to achieve public health goals. Without such collaboration, these goals would not have succeeded.” (Trade association).
Conversely, those against industry involvement through MSG rejected these claims of effectiveness, noting that “We identify no evidence of efficacy for continuing dialogue with the alcohol industry and deeply regret the disproportionate attention given to economic operators in the plan” (NGO). Similarly, another NGO argued that
In the action plan, the alcohol industry should be dealt with in a single paragraph, emphasizing that neither self-regulation, nor corporate social responsibility has brought any positive changes to the alcohol burden; that the alcohol industry is interfering against WHO-recommended alcohol policy solutions, delaying, derailing and destroying attempts to implement the WHO GAS. (NGO)
By this, it clearly contesting the suggested efficiency and effectiveness of industry inclusion through MSG.
Arguments centred around fair procedure and performance
The main arguments related to fair procedure, referred to in 51% of responses centred around conflicts of interest (COI) and indicated strong disagreement between respondents. Some NGOs and academics referred to the ‘inherent’ COI between some industries and public health as a key rationale for not including industry actors in MSG. One NGO, for example, noted that
the alcohol industry has a clear conflict of interest in public health policy settings due to the health impact of its products and reflected in its financial and legal obligations to shareholders. Therefore, alcohol industry representatives have no place in the formulation or enforcement of policies to reduce alcohol harm. (NGO)
On the other hand, some respondents perceived COI tools as enabling MSG, with one member state for example suggesting that “COI mitigation and management tools, such as Codes of Conduct, can be used to increase transparency and reduce risk around actual COIs while promote [sic] successful multi-stakeholder partnerships.” (State). However, exactly this was deemed a risk by others, summarised by one NGO as
a tension between an effort to try and safeguard policy and programming endeavours in nutrition and a simultaneous reaffirmation of the MSI/PPP [multistakeholder initiative / public-private partnership] paradigm. However, this paradigm has CoI intrinsically built in and erodes decision-making in public interest. […] Redefining of the CoI concept to serve the MSI/PPP paradigm can lead only towards further undermining rather than much needed strengthening of CoI safeguards. (NGO)
In relation to human dignity or distributive justice, which were referred to in 4.4% and 7.4% of responses respectively, notably not by those in favour of MSG. Some NGOs emphasised the obligation of states and public institutions to protect human rights, using this narrative to problematise industry’s involvement through MSG. As one NGO argued, “industry players have capitalised on the notion of public private partnerships and have consistently positioned themselves as contributors to development and job creation despite the impact of the production process on natural resources in countries” (NGO). This aligns with another respondent’s assertion that the “further entrenchment of the MSI/PPP model disregards the risks this model brings to human rights” (NGO).