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Public Private Partnerships fighting obesity in Europe

Does the Nordic region represent a special case?1
Vaincre l’obésité en Europe par des Partenariats Public-Privé – La région nordique représente-t-elle un cas particulier ?
Anita Borch and Gun Roos

Abstracts

According to the Commission of the European Communities, Public Private Partnerships (PPPs) are ‘the cornerstone’ to tackle obesity today. This research analyzes if and how current PPPs combating obesity in Europe vary between Nordic social-democratic, conservative, liberal, Mediterranean, and East European regimes. It identifies main characteristics of PPPs focusing on cooperating partners, target groups, and objectives. Some variations between European regimes were found, but a general conclusion is that most PPPs fighting obesity in Europe aim at changing consumers’ eating and exercise practices through information. As information-based PPPs may increase social inequality, it is suggested that more efforts should be made to establish PPPs aiming to change the structures in society that make it difficult for disadvantaged groups to ‘choose’ health. The results of this study may be interpreted as indicating tendencies towards standardization and harmonization of nutrition policies and food culture across Europe.

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Introduction

  • 1 This publication arises from the project “Obesity Governance”, which has been made possible by the (...)

1Overweight and obesity are considered to be one of the most serious public health challenges in Europe (Branca et al., 2007). According to the Organisation for Economic Co-operation and Development (OECD, 2010), the prevalence of obese people has more than doubled in the last 20 years. Today, more than half of the adult population is overweight or obese. Most at risk are socio-economically disadvantaged groups and minorities (Drewnowski, 2009; Grøholt et al., 2008; Roos, 2010). The obesity rate tends to be higher in liberal regimes characterized by high access to high-energy food and a high level of competition, economic uncertainty, and social inequality (Offer et al., 2010).

2In previous research obesity tends to be seen as a complex phenomenon linked to social and economic changes in modern societies. One hypothesis has been that the increase of obesity is caused by the obesogenic environment, a combination of highly accessible high-energy food and a sedentary lifestyle. Another explanation has been that the increase reflects changes in welfare regimes and the rise of market-liberal ideologies (Holm, 2012; Offer et al., 2010). Moreover, the varying obesity rates that have been observed in European countries have been seen as a possible outcome of an environmental effect where local food cultures have diminished or intensified the effects of the increased energy supply in the global food system (Swinburn et al., 2011). A key question has been how obesity can be regulated. Amongst other things, it has been recommended that prevention of obesity should be guided by a socio-ecological framework that focuses on interactions between a person’s physical, social, and cultural environments (Caprio et al., 2008; Holm, 2012). The main goals of the World Health Organization and current obesity prevention programs and nutrition policies in Europe have been to modify the obesogenic food environment, increase the cooperation among governments, food industry and research, and reduce consumer access to unhealthy foods (Branca et al., 2007).

3In 2007 the Commission of the European Communities (2007) singled out Public Private Partnerships (PPPs) to be ‘the cornerstone’ to tackle obesity. The need for new governance has also been emphasized in a recent study of Gortmaker et al. (2011) concluding that a global approach involving public and private sector at all levels of society is needed to combat obesity. By PPPs we mean network-based (non-hierarchical) constellations of at least two representatives from authorities, non-profit actors and for-profit actors collaborating in order to fulfill a goal, in this case to prevent and reduce the harm of obesity. Thus, although the name ‘PPP’ suggests that this is a form of governance that by definition comprises representatives from both public and private sector, it should be noted that PPPs in this paper can also comprise representatives from two different public sectors: authorities and non-profit actors like NGOs, research institutes and universities. Examples could be the Swedish front-of-pack labeling ‘the Keyhole’ which was introduced in 1989 to help consumers to choose healthy products, the Hungarian information campaign ‘NutriKids’ which was established in 2003 to educate children to keep fit, and the Irish program ‘Incredible Edibles’ which was launched in 2009 to promote fruit and vegetables consumption by urging schools to grow them themselves together with children. Other PPPs’ aims could be to establish and run research projects or networks, or product reformulation, guidelines for marketers and producers, political programs, legislation, exercise programs, and treatment programs (Jørgensen et al. 2012; Roos, 2011).

4Whereas some studies conclude that PPPs form contexts of shared knowledge, responsibility and power in ways that serve their cause, others question the PPPs’ legitimacy and effectiveness (Christou & Simpson, 2009). A common criticism has been that the private actors participating in PPPs not only aim at realizing social goal, but also the financial goals of their own businesses. The ambiguity that comes to expression in previous research may have many explanations. Taken into account that PPP is a form of governance that increases and legitimizes the role of businesses and the market in political decision making processes, one explanation might be that right- and left-hand researchers have highlighted the positive and negative effects of PPPs respectively. Another and probably more plausible explanation is, however, that some PPPs are more efficient than others.

5So far most research on PPPs has been case studies focusing on one or more PPPs, their objectives, challenges, and possible consequences (e.g., Alam & Roman, 2011; ASTHO & NIHCM, 2007; Carlin, 2008; Cluss et al., 2010; Lopez, 2008; McDermott et al., 2009). Another body of literature has been theoretical discussions drawing on new governance literature (e.g. Lindner, 1999; Simon & Fielding, 2006; Skietrys et al., 2008). To our knowledge, a quantitatively oriented comparative study exploring current PPPs and their potentials for improvement has so far not been conducted.

6To reduce this gap of knowledge, this study reports the main results of a quantitatively oriented analysis of 165 PPPs aimed at combating obesity in 28 European countries in 2010. The goal is to identify typical aspects of current PPPs combating obesity in Europe today focusing on their main characteristics: the cooperating partners, their target groups, and their objectives. The main aim of this article is to explore if the Nordic region and Nordic food culture represent a special case, and if and how PPPs vary between Nordic and other European countries. We will discuss whether or not these variations can be interpreted in light of Esping-Andersen’s (1990) classical welfare theory and one of its renewals: the socio-economic model of Steurer and Hametner (2010). A basic assumption is that the main characteristics of PPP vary between European regimes depending on these regimes’ view of the concept of ‘responsibility’. A brief introduction of these theories and the assumptions that we have derived from them are given in the next section.

The diversified view on responsibility: theory and assumptions

7At one extreme, obesity can be seen as a matter of individual choice. From this perspective, people ‘choose’ to be overweight simply because they eat too much and exercise too little (e.g. Weber Shandwick, 2004). On the other hand, obesity can be viewed as a structural problem. From this point of view, governments, non-governmental organizations (NGOs), and the food industry must be responsible, both because obesity is the result of structural conditions caused by entities other than the individual consumer, and because people at risk of developing obesity problems obviously have difficulties regulating their exercise practices and intake of food and drinks. If and how these views on obesity vary between European countries, is uncertain. Based on the theories of Esping-Andersen (1990) it might be assumed that the view on obesity varies depending on how they tend to perceive the concept of responsibility. According to this theory, Europe can be divided in three regimes, ‘the social-democratic’, ‘the conservative’ and ‘the liberal’. In social-democratic regimes, such as the Nordic countries, responsibility tends to be placed on governments. In conservative regimes, such as Austria, France, Germany, and Italy, responsibility more often falls on non-governmental organizations (NGOs), the churches, and the family. In liberal regimes, such as in the USA, Canada, and Australia, responsibility tends to be placed on the market (individuals and businesses). Social-democratic regimes are associated with egalitarian, welfare ideologies, and financial benefits are given to all people, although to varying degrees. Liberal regimes, however, tend to bestow financial benefits only to people in need.

8Since the model was published in 1990, it has been tested and renewed several times. A typical example of a renewal model is given by Steurer and Hametner (2010).

Figure 1: Overview of five socioeconomic models in Europe

Figure 1: Overview of five socioeconomic models in Europe

Source: Steurer and Hametner, 2010

9* According to Steurer and Hametner (2010), the socioeconomic models applied in the countries listed in brackets are disputed because they resemble a mixed rather than an ideal type model

10As illustrated in Figure 1, renewed models based on Esping-Andersen’s theory tend to distinguish between conservative and Mediterranean regimes and involve East European Countries (EECs). Whereas Mediterranean regimes are described as “mixed” characterized with a fragmented and “clientistic” support, the EECs are described as “developing” states with considerable variations.

11Inspired by these theories, several assumptions can be made: 1) PPPs established in social-democratic regimes tend to involve authorities and aim at changing the structures that make it difficult for consumers to choose health, rather than changing the behavior of consumers through information. 2) PPPs introduced in conservative and liberal regimes will tend to involve nonprofit actors and for-profit-actors respectively. 3) The PPPs will aim at changing the behavior of consumers rather than the structures framing this behavior.

12The analysis of Mediterranean regimes and the EECs will tend to be mixed or diversified and hence shows no clear variations that can be associated with the liberal, conservative or social-democratic regimes.

13Before these assumptions are empirically explored, the methodology behind this research is described in the next section.

Method

14The analysis is part of the EU-funded project Obesity Governance (2010-2012), which aimed to 1) identify and analyze national and local PPPs in European countries, 2) describe and evaluate best practices of PPPs in Europe, and 3) discuss the transferability of these practices to other countries. Research teams from six European countries gathered information about PPPs in 27 EU members plus Norway.

15The research process proceeded as follows. First, information was searched from the home pages of governments, NGOs and businesses. Each research team aimed at contacting public government authorities in nutrition and food, consumer organization, branch organizations, trade association (not companies directly), relevant health organizations and other possible actors that could provide information. As a next step, key persons in these organizations were interviewed via e-mail, telephone, or face-to-face. The interviews followed a template requesting the country in which the PPPs were identified, the name of the initiative, source of information, substantial description, goal and character, main stakeholders, initiative-taking individuals, financial matters, legal matters, conflicts and alliances among stakeholders, results and other relevant information, as well as possible candidates to the best practice analysis. The data collected in the Obesity Governance project was coded into a SPSS matrix and statistically analysed. PPPs that did not include stakeholders of at least two different categories (for instance at least one authority and at least one nonprofit actor) were removed from the database, as they did not satisfy the project’s formal PPP criteria (Stø, 2010). Thus, of totally 236 reported PPPs (Roos, 2011) only 165 were included in the analysis.

16The coding of the PPPs followed the following set of questions: What partners are involved? What social groups or institutions are targeted? What are the PPP’s goals? Do the cooperating partners, the target group or the goals vary between Nordic social-democratic regimes and other European regimes?

17The cooperating partners were coded in three main categories: 1) Authorities, including governments at global, national, regional and local level; 2) Non-profit actors, including NGOs, food, sports and other health organizations, universities and other research institutions, schools and other educational centers, treatment centers and consumer organisations: and 3) For-profit actors, including food businesses and other industries, as well as their foundations.

18The target groups were coded in two main categories: 1) Consumers (including ‘families’ and ‘parents’); and 2) Institutions, including authorities, nonprofit actors and for profit actors.

19The PPPs’ objectives were coded in two main categories: 1) Individual-oriented goals, comprising PPPs aiming to change consumers’ behavior through information campaigns, labelling, and commercials; and 2) Structural-oriented goals, comprising PPPs aiming to change the structures influencing consumers’ behavior, that is, through the establishment of research projects and networks, product development, guidelines, legislation, political programs, exercise programs, and treatment.

20Finally, the PPPs’ country of origin was coded in five regimes: 1) Social-democratic regimes, consisting of PPPs from Finland, Denmark, Sweden, and Norway; 2) Conservative regimes, consisting of PPPs from Germany, Austria, Belgium, Luxemburg, France, and the Netherlands; 3) Liberal regimes, consisting of PPPs from UK and Ireland; 4) Mediterranean regimes, consisting of PPPs from Spain, Portugal, Italy, Greece, Cyprus, and Malta; and 5) East European Countries (EEC), consisting of PPPs from Estonia, Latvia, Lithuania, Bulgaria, Czech Republic, Hungary, Poland, Slovakia, Slovenia, and Romania.

21The data matrix is in other words specially made to answer the research questions of this paper. Thus, although this strengthens the validity of the research, it cannot be ruled out that another research design (e.g. based on a more complicated set of variables or a more qualitatively, oriented research technique) would have derived other results. Research based on other methodologies should therefore be made to eliminate this possible source of error. Note also that PPPs from the liberal regimes (UK and Ireland) and to some extent from the conservative regimes (Germany and Austria) and the EECs have been underreported according to the country reports. Some reservations regarding the research results must therefore be made.

Results

Table 1: Partners, target groups and objectives of PPPs, in Europe and by regime

Euro-pe

Social-

Demo-cratic

Con-servative

Liberal

Medi-terranean

EEC

Partner:

-Authorities

-Non-profit

-For-profit

124

141

127

15

24

28

41

51

43

9

9

13

27

27

15

32

31

29

Target:

-Consumer

-Institution

136

87

24

16

48

27

7

9

27

16

31

19

Goal:

-Consumer info.

-Structural changes

116

89

17

18

41

28

4

11

25

17

30

15

N

165

31

54

14

30

37

22All types of stakeholders were involved in the European obesity-related PPPs, but nonprofit actors (n=136) were more frequently involved than for-profit actors (n=127) and authorities (n=124). Most PPPs targeted individual consumers (n=136) rather than institutions (n=87). Most PPPs also aimed at changing the behavior of individual consumers through information (n=116) rather than changing the structures that make it easier for consumers to choose health (n=89). Interestingly, these results for all Europe are in line with the tendencies that we, based on Esping-Andersen’s (1990) welfare theory, expected to mainly find in conservative regimes. Key features of the conservative regimes are that they have less redistributive effects and are more likely to place social political responsibility on the private sector (the civil society and businesses) than the social-democratic regimes. The general ‘soul’ of PPPs fighting obesity in this particular sample of European PPPs seems in this respect to be ‘conservative’. We will next explore the main characteristics of PPPs in the different European regimes.

2331 PPPs were observed in Nordic social democratic regimes. Most of these involved for-profit actors (n=28) and non-profit actors (n=24) and to a smaller extent authorities (n=15). The analysis also suggested that individual consumers (n=24) were more frequently targeted than institutions (n=15). 18 PPPs aimed at changing the structures that make it difficult for consumers to choose health, and 17 PPPs aimed at changing consumer’s behavior through information.

2454 PPPs were identified in conservative regimes. Most of these involved nonprofit actors (n=51), but there were also many for-profit actors (n=43) and authorities (n=51) involved. Individual consumers (n=48) were more frequently targeted than institutions (n=27) and there were more PPPs aiming at changing the behavior of consumers (n=41) than changing the structures that make it easier for the consumer to choose health (n=28).

25Due to the underreporting of PPPs from liberal regimes, the sample only comprises 14 PPPs from these regimes. The PPPs involved most for-profit actors (n=13), but also authorities (n=9) and nonprofit actors (n=9). 11 targeted institutions and nine PPPs targeted individual consumers. 11 PPPs aimed at changing the structures that make it difficult for consumers to choose health, whereas four aimed at changing the behavior of consumers through information.

2630 PPPs were identified in Mediterranean regimes. The PPPs more frequently involved authorities (n=27) and nonprofit actors (n=27) than for-profit actors (n=15). Individual consumers (n=27) were more frequently targeted than institutions (n=16), and the PPPs were more frequently aiming at changing the behavior of consumer through information (n=25) than changing the structures that make it difficult for consumers to choose health (n=17).

27Finally, 37 PPPs were recognized in the EECs. The PPPs involved all types of stakeholders: authorities (n=32), nonprofit actors (n=31), and for-profit actors (n=29). Individual consumers (n=31) were more frequently targeted than institutions (n=19), and the PPPs more frequently aimed at changing the behavior of consumers (n=30) than changing the structures impacting this behavior (n=15).

Discussion

28This research suggests that PPPs fighting obesity are identified in all European countries, except Luxemburg, Malta, and Lithuania. This indicates that obesity-related PPPs are today used as a means to tackle obesity in most European regimes.

29One finding is that PPPs fighting obesity today comprise all types of cooperating partners: authorities, non-profit actors and for-profit actors. Indeed, there is a small tendency that non-profit actors in general and health organisations in particular are more frequently involved than others. The tendency is however weak and can be the result of coincidence.

30The equal distribution of partners may indicate that PPPs are not dominated by one particular type of actor, and hence that PPPs seem to form contexts of what we preciously have called ‘shared knowledge, responsibility, and power’. It should however be noted that little is known about the role different actors tend to take in the PPPs. Whether or not one partner tends to take a dominating or subordinated role in PPPs is in other words uncertain and should be subject for further studies.

31Other findings are that individual consumers are more frequently targeted than institutions, and that PPPs are more frequently aimed at changing the behavior of consumers through information rather than changing the structures that frame this behavior. This indicates that obesity tends to be regarded as an individual problem. That is, obesity is a problem up to the individual consumer and their families to solve rather than a structural problem, which is up to institutions like authorities and the food industry to regulate. Research indicates, however, that obesity is the result of both individual factors such as the predisposition of the human body to store fat, personal food and exercise preferences, and structural factors such as access to and marketing of food and exercise practices (Lang & Rayner, 2005). Research also suggests that information-based measures such as labelling are less frequently used by people with lower levels of education (Roos, 2007), and that an energy-dense diet may be cheaper than a healthy one (Drewnowski, 2009). Hence, to improve the ability of PPPs to combat obesity and reduce the chance of increasing social inequality, more PPPs should target institutions and thus make it easier for consumers in general, and socio-economically disadvantaged groups in particular, to ‘choose’ health.

32The main question posed in this paper was whether the Nordic region represents a special case. Based on the theories of Esping-Andersen (1990) and one of its renewals, the socio-economic model of Steurer and Hametner (2010), we assumed that Nordic social democratic regimes would tend to comprise authorities and aim at changing the structures that make it difficult for consumer to choose health. Liberal and conservative regimes, on the other hand, were assumed to comprise non-profit and for-profit actors respectively, and aim at changing the behavior of consumers through information. The PPPs of Mediterranean regimes and the EECs were expected to be mixed or diversified and hence show no clear variations that can be associated with liberal, conservative or social-democratic regimes. The results indicate that to some extent current PPPs can be interpreted in light of Esping-Andersen’s theories. The regimes that tended to act most as expected were the conservative regimes. In these regimes most PPPs comprise non-profit actors and aim at changing consumers’ behavior through information rather than through the structures that influence this behavior. Also, the Mediterranean nations and the EECs can be associated with the PPPs of conservative regimes. The regimes that tended to act least as expected were the Nordic social democratic regimes and liberal regimes. In contrast to what we expected, most of the PPPs tended not to comprise authorities. Nor did they tend to target institutions rather than consumers. That being said, the number of PPPs aiming at changing the structures influencing consumers’ behavior was not lower than the PPPs aiming at changing consumers’ behavior through information, but at the same level.

33Thus, taking into account that the Nordic countries are associated with egalitarian welfare ideologies, it may seem paradoxical that the number of information-based PPPs was not significantly higher in these regimes than in other regimes (Kjærnes & Roos, 2012). As expected, liberal regimes tended to comprise for-profit actors. Unexpectedly, however, most PPPs aimed at changing the structures influencing consumers’ behavior rather than changing the consumers’ behavior through information. Reservations must however be made regarding this result, due to the underreporting of PPPs from liberal regimes. The fact that current PPPs extent can only be interpreted to some extent in light of the theories of Esping-Andersen’s and Steurer and Hametner (2010) may reflect an anomaly of the renewed welfare model when it comes to explaining food regulation in European countries, or social policy in general.

34From this we may conclude that the PPPs of the Nordic region do not differ significantly from the PPPs of other European regimes. Although there are variations between European regimes, most PPPs fighting obesity in Europe today aim at changing consumers’ eating and exercise practices through information and pay less attention to the structural conditions that make it difficult for consumers to ‘choose’ health. This is in line with previous research suggesting that Nordic countries do not form a distinctive group when it comes to obesity-related issues (Offer et al., 2010) and that Nordic nutrition policies seem to be oriented towards harmonization with the EU by focusing on public health, self-regulation and individual responsibility (Kjærnes, 2008; Kjærnes & Roos, 2012). The research also suggests that although current PPPs tend to comprise all types of actors, health organisations and other non-profit actors seem to be more frequently involved than others. Also this finding, which basically indicates that non-profit actors play a significant role in current PPPs, is in line with previous research discussing the development towards new governance and the growing significance of international regulators like WTO, WHO and the European Commission in current policy. A central argument made by Kurzer & Cooper (2011) is that the European Commission have adopted WHO’s call for bringing together NGOs, producers, experts and public authorities in action against obesity. All in all, the research supports previous research on regulation of obesity suggesting that shifting boundaries between the state and the market and that transnational policy actors and food industry play central roles in current nutrition policy development.

35The results can, therefore, be interpreted as indicating tendencies towards standardization and harmonization of nutrition policies Europe. The possible anomaly of the renewed welfare model observed in this study may in this respect reflect a general tendency in Europe to base nutrition and health policy on the very same sources of knowledge. The general focus on information based strategies suggests that there is potential for improving current PPPs fighting obesity in Europe. As information-based PPPs may increase social inequality, special attention should be paid to PPPs aiming to change the structural conditions that make it easier for consumers in general, and socially-disadvantaged groups in particular, to choose health. Indeed, PPPs aiming to change consumers’ behavior through information may seem more convenient and cheaper to implement than more a structurally oriented PPP. However, if they are less efficient, they may draw attention away from the PPPs that actually make a change and hence be more expensive in the long run.

36In the context of this special issue on food culture, it should also be noted that most PPPs identified in this research appear to ignore the social and cultural aspects of food. Policy of obesity and policy of food culture seem to make up two distinct discursive spheres by belonging to the health and cultural sectors, respectively. As mentioned in the introduction, there is, however, reason to believe that there is a close relationship between obesity and (food) culture (Caprio et al., 2008). Amongst other things, Swinburg et al. (2011) suggest that local food cultures have diminished or intensified the effects of the increased energy supply in the global food system. Such theories, which basically imply that local food cultures can be used as effective tools of governance regulating obesity, are in line with anthropologists who have long written about obesity as a culture-bound syndrome in western societies (Ritenbaugh, 1982). Subsequently it should be emphasized that the structurally oriented PPPs that we have recommended should not only focus on political and economic conditions preventing and reducing the harm of obesity, but on social and cultural aspects as well. For example, PPPs aiming to innovate new or reformulate old local food cultures could be established to improve citizens’ health. Public exercise services making use of local, natural resources in new and attractive ways could be initiated. Current PPPs tend to treat obesity in Europe as if it was one cultural phenomenon. By emphasizing the social and cultural aspects of obesity, the more complex and multifaceted aspects of obesity – its many meanings, causes, effects and potential counteractive strategies embedded in local societies – may be revealed.

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Notes

1 This publication arises from the project “Obesity Governance”, which has been made possible by the means of a financial contribution from the Programme of Community Action in the Field of Public Health 2003-2008, of the European Commission.

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List of illustrations

Title Figure 1: Overview of five socioeconomic models in Europe
Credits Source: Steurer and Hametner, 2010
URL http://aof.revues.org/docannexe/image/7286/img-1.jpg
File image/jpeg, 589k
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References

Electronic reference

Anita Borch and Gun Roos, « Public Private Partnerships fighting obesity in Europe », Anthropology of food [Online], S7 | 2012, Online since 11 January 2013, connection on 24 March 2017. URL : http://aof.revues.org/7286

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About the authors

Anita Borch

SIFO - National Institute for Consumer Research, Norway, anita.borch@sifo.no

Gun Roos

SIFO - National Institute for Consumer Research, Norway, gun.roos@sifo.no

By this author

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Copyright

Licence Creative Commons
Anthropologie of food est mis à disposition selon les termes de la licence Creative Commons Attribution - Pas d'Utilisation Commerciale - Pas de Modification 4.0 International.

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