Background: With multi-stakeholder approaches central to efforts to address global health challenges, debates around conflict of interest (COI) are increasingly prominent. The World Health Organization (WHO) recently developed a proposed tool to support member states in preventing and managing COI in nutrition policy. We analysed responses to an online consultation to explore how actors from across sectors understand COI and the ways in which they use this concept to frame the terms of commercial sector engagement in health governance. Methods: Submissions from 44 Member States, international organisations, non-governmental organizations (NGOs), academic institutions and commercial sector actors were coded using a thematic framework informed by framing theory. Respondents’ orientation to the tool aligned with two broad frames, ie, a ‘collaboration and partnership’ frame that endorsed multi-stakeholder approaches and a ‘restricted engagement’ frame that highlighted core tensions between public health and food industry actors. Results: Responses to the WHO tool reflected contrasting conceptualisations of COI and implications for health governance. While most Member States, NGOs, and academic institutions strongly supported the tool, commercial sector organisations depicted it as inappropriate, unworkable and incompatible with the Sustainable Development Goals (SGDs). Commercial sector respondents advanced a narrow, individual-level understanding of COI, seen as adequately addressed by existing mechanisms for disclosure, and viewed the WHO tool as unduly restricting scope for private sector engagement in nutrition policy. In contrast, health-focused NGOs and several Member States drew on a more expansive understanding of COI that recognised scope for wider tensions between public health goals and commercial interests and associated governance challenges. These submissions mostly welcomed the tool as an innovative approach to preventing and managing such conflicts, although some NGOs sought broader exclusion of corporate actors from policy engagement. Conclusion: Submissions on the WHO tool illustrate how contrasting positions on COI are central to understanding broader debates in nutrition policy and across global health governance. Effective health governance requires greater understanding of how COI can be conceptualised and managed amid high levels of contestation on policy engagement with commercial sector actors. This requires both ongoing innovation in governance tools and more extensive conceptual and empirical research.

Background The UN system’s shift towards multistakeholder governance, now embedded in the Sustainable Development Goals (SDGs), invites a broad range of actors, including the private sector, to the policymaking table. Although the tobacco industry is formally excluded from engagement, this approach provides opportunities for other unhealthy commodity industries to influence the World Health Organization’s (WHO’s) non-communicable disease (NCD) agenda. Focusing on the food industry, this research maps which actors engaged with WHO consultations, and critically examines actors’ policy and governance preferences as well as the framing they employ to promote these preferences in the global context. Methods All written responses from food industry actors to publicly available NCD-relevant WHO consultations held between September 2015 and September 2018 were identified, totalling forty-five responses across five consultations. A qualitative frame analysis was conducted to identify policy positions expressed by respondents, as well as arguments and frames used to do so. Results Though no individual companies responded to the consultations, the majority of participating business associations had some of the largest multinational food corporations as members. Respondents overarchingly promoted non-statutory approaches and opposed statutory regulation and conflict of interest safeguards. To this purpose, they framed the food industry as a legitimate and necessary partner in policymaking, differentiating themselves from the tobacco industry and referencing a history of successful collaboration, while also invoking multistakeholder norms and good governance principles to portray collaboration as required. Respondents contrasted this with the limits of WHO’s mandate, portraying it as out of step with the SDGs and framing NCD decision-making as a matter of national sovereignty. Conclusion We observed that the UN’s call for partnerships to support the SDGs is invoked to defend corporate access to NCD policy. This highlights the need for more cautious approaches which are mindful of the commercial determinants of health. Systematic opposition to regulation and to governance approaches which may compromise commercial actors’ insider role in global health by food industry actors shown here, and the strategic use of the Sustainable Development agenda to this purpose, raises questions about the value of collaboration from the perspective of international health agencies such as WHO.

IntroductionThis paper explores implementation of Article 5.3 of the WHO Framework Convention on Tobacco Control in Ethiopia. The analysis highlights how operationalising key requirements of Article 5.3, such as minimising policy engagement with the tobacco industry, has been mediated by path-dependent processes of stakeholder consultation and collaboration that have persisted following privatisation of Ethiopia’s state-owned tobacco monopoly.MethodsWe conducted semistructured interviews with key officials (n=21) working in tobacco control policy, with high levels of access secured across ministries and agencies beyond health.ResultsWe found contrasting levels of awareness of Article 5.3 across government sectors, with extremely limited awareness in departments beyond health. The data also highlight competing ideas about conflict of interest, in which recognition of a fundamental conflict of interest with the tobacco industry is largely confined to health actors. Beyond limited cross-sectoral awareness and understanding of Article 5.3, gaps in implementation are exacerbated by assumptions and practices around stakeholder consultation, in which attempts to minimise policy interactions with the tobacco industry are mediated by institutionally embedded processes that presume active engagement. The results also highlight a continuation of the close relationship between the Ethiopian government and tobacco monopoly following its privatisation.ConclusionThe Ethiopian government’s recent achievements in tobacco control legislation require that policymakers are actively supported in reconciling perceived tensions and requirements for stakeholder consultation. Effective tobacco control governance would be further enhanced by enabling government agencies to more clearly identify which interactions with the tobacco industry are strictly necessary under Article 5.3 guideline recommendations.

IntroductionBangladesh has not yet adopted measures to implement Article 5.3 of the WHO Framework Convention on Tobacco Control. The National Tobacco Control Cell (NTCC) has drafted a guideline for implementation, but progress has stalled amid high levels of tobacco industry interference in public policy. This paper examines the barriers to minimising industry interference in a context of close relationships between government officials and tobacco companies.MethodsIn-depth interviews were conducted with government officials, representatives from civil society, think tank and media organisations, and academic researchers. The data were analysed using a ‘3 Is’ framework developed within the political sciences, emphasising the interactive role of ideas, interests and institutions in policy change.ResultsThe findings indicate that policy ideas about protecting public health policy making from tobacco industry interests are largely restricted to the Ministry of Health and Family Welfare, and the NTCC specifically. Both individual and institutional conflicts of interest emerge as key barriers to progress to minimising industry interference and for tobacco control governance more broadly. The data also suggest that development of an Article 5.3 guideline has been shaped by the perceived interests of political actors and institutions, and the institutional position of the NTCC, constrained by limits on its resources, authority and isolation from other ministries.ConclusionNTCC’s initiatives towards implementing Article 5.3 constitute an important opportunity to address conflicts of interest that restrict tobacco control in Bangladesh. Progress in minimising industry interference is essential to realising the commitment to being smoke free by 2040.

IntroductionAccelerating progress on tobacco control will require Article 5.3 of the WHO Framework Convention on Tobacco Control to be systematically integrated into policies and practices of sectors beyond health at diverse government levels. However, no study has explored implementation challenges of Article 5.3 within multilevel systems such as India, where political decisions on tobacco control occur at diverse government levels, which may constrain action at local level.MethodsBased on 33 semi-structured interviews with diverse government and civil society stakeholders across four districts in Karnataka, India (Mysore, Mangalore, Bengaluru (rural) and Udupi), this study examines challenges to implement Article 5.3 arising from competing agendas and policies of different actors at multiple levels.ResultsOur analysis reveals generally low levels of awareness of Article 5.3 and its guideline recommendations, even among those directly involved in tobacco control at district level. Efforts to implement Article 5.3 were also challenged by competing views on the appropriate terms of engagement with industry actors. Scope to reconcile tensions across competing health, agriculture and commercial agendas was further constrained by the policies and practices of the national Tobacco Board, thereby undermining local implementation of Article 5.3. The most challenging aspect of Article 5.3 implementation was the difficulties in restricting engagement by government officials and departments with tobacco industry corporate social responsibility initiatives given national requirements for such activities among major corporations.ConclusionsPromoting effective implementation of Article 5.3 in Karnataka will require policymakers to work across policy silos and reconcile tensions across India’s national health and economic priorities.

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IntroductionIn federal systems, state and local governments may offer opportunities for innovation in implementing the WHO Framework Convention on Tobacco Control (FCTC). This paper explores the implementation of WHO FCTC Article 5.3 within India’s federal system, examining how its guidelines have been operationalised across states and union territories.MethodsInterviews with officials from government and civil society organisations across key states, and a document review of state government and district administration notifications adopting Article 5.3 guidelines between 2015 and 2019.ResultsThe data reveal subnational leadership in formulating intersectoral committees, which are designed to limit interactions with the tobacco industry, and corresponding measures to reject partnership and conflicts of interest for government officials. There are notable omissions across states and union territories in adoption of key Article 5.3 guidelines; only four districts and state governments refer to regulating aspects of ‘socially responsible’ industry activities, and no notifications include measures to prevent the tobacco industry receiving preferential treatment or requiring that information provided by industry actors be transparent and accountable. Interview data indicate that dynamics of notification across states have been shaped by lesson drawing and the catalytic role of civil society. The adoption of protocols is impacting on the practices of health officials, but there are concerns about engagement by other departments and the regulatory capacity of empowered committees.ConclusionThe spread of state- and district-level policies illustrates opportunities federal structures can provide for accelerating tobacco control. Given significant omissions and policy tensions, there remains a need for national action to build on these innovations, including in revisions to India’s tobacco control legislation.