# Public-Private Partnerships in Mexico: Implications of Engaging With the Food and Beverage Industry for Public Health Nutrition

Angela Carriedo, Enaí Ojeda, Eric Crosbie, Mélissa Mialon

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Angela Carriedo, Enaí Ojeda, Eric Crosbie, Mélissa Mialon. Public-Private Partnerships in Mexico: Implications of Engaging With the Food and Beverage Industry for Public Health Nutrition. International journal of health policy and management, 2024, 23, 10.34172/ijhpm.2024.8008. http://05038680

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# Public-Private Partnerships in Mexico: Implications of Engaging With the Food and Beverage Industry For Public Health Nutrition

Angela Carriedo, Enaí Ojeda, Eric Crosbie, Mélissa Mialon

DOI: https://doi.org/10.34172/ijhpm.2024.8008

## Article History:

Received Date: March 4, 2023

Accepted Date: January 28, 2024

epublished Author Accepted Version: January 29, 2024

**Copyright:** © 2024 The Author(s); Published by Kerman University of Medical Sciences. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**Please cite this article as:** Carriedo A, Ojeda E, Crosbie E, Mialon M. Public-private partnerships in Mexico: implications of engaging with the food and beverage industry for public health nutrition. *Int J Health Policy Manag*. 2023;x(x):x-x. doi: 10.34172/ijhpm.2024.8008

This PDF file is an Author Accepted Manuscript (AAM) version, which has not been typeset or copyedited, but has been peer reviewed. IJHPM publishes the AAM version of all accepted manuscripts upon acceptance to reach fast visibility. During the proofing process, errors may be discovered (by the author/s or editorial office) that could affect the content, and we will correct those in the final proof.

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# Public-Private Partnerships in Mexico: Implications of Engaging With the food and Beverage Industry for Public Health Nutrition

Angela Carriedo*¹, Enaí Ojeda², Eric Crosbie³,⁴, Mélissa Mialon⁵

1. World Public Health Nutrition Association, London, UK

2. Instituto Nacional de Salud Pública, Morelos, Mexico

3. School of Public Health, University of Nevada Reno, Reno, NV, USA

4. Ozmen Institute for Global Studies, University of Nevada Reno, Reno, NV, USA

5. Trinity College Dublin, Dublin, Ireland

**Correspondence to:** Angela Carriedo; angela_carriedo@yahoo.com

## Abstract

**Background:** In the last few years, Mexico adopted public health policies to tackle non-communicable diseases, such as front of package nutrition labelling, food marketing restrictions to children, and a soda tax. In parallel, transnational food and beverage industries (F&BI), their allies, and the government have agreed on public-private partnerships (PPPs) to implement policies or deliver programs. However, research has questioned the benefits of PPPs and exposed its limitations as a suitable mechanism to improve public health. This study analyses how four PPPs between the Mexican government, the F&BI, and allies are working to achieve their goals. We critically assessed the objectives, scope, reported impacts, governance principles and perceived risks and benefits for the public health agenda of these PPPs.

**Methods:** This qualitative study is based on 26 interviews with key actors, and 170 publicly available documents, including 22 obtained through freedom of information (FOI) requests related to four purposively selected PPPs aiming to improve health.
**Results:** We found that the four PPPs studied had minimal public information available on their implementation and impact. The private partners tend to dictate the design, information management, and implementation of the programs, while promoting their brands. Few independent evaluations of the PPPs exist, and none reported on their effectiveness or public health benefits. Good governance principles, such as accountability, transparency, fairness, participation, integrity, and credibility, were barely followed in each of the cases studied. Public officials did not automatically question the conflict of interest of such arrangements. When there were conflicts of interest, the potential risks these posed did not always outweigh the financial benefits of working with the F&BI and its allies.

**Conclusion:** The four PPPs studied produced minimal gains for public health while boosting credibility for the participating transnational F&BIs. It shows the lack of awareness of how these PPPs might be hindering public health gains.

**Keywords:** Public-Private Partnerships; Governance; Nutrition Programs

## Implications for policymakers

* PPPs between governments and the F&BI and its allies should be questioned in terms of the potential negative implications they could have, notably because of the existence of a conflict of interest, a lack of transparency and good governance principles.

* Transparency, accountability, and ethical issues identified in the four PPPs under study are examples of issues to be considered at national and subnational levels to avoid the negative effects of partnering with transnational F&BI.

* Governments should reassess the mechanisms and tools in place to avoid conflict of interests and industry interference in public health program implementation when engaging in PPPs.

## Implications for public

Our results show a lack of synergy between the goals, aims, and actions described by the public and private partners involved in delivering the intended public health benefits in four PPPs. These PPPs show minimal gains for public health policy while boosting the credibility of the transnational F&BI partners. PPPs are a corporate political activity aiming to minimise negative effects on transnational F&BI's economic gains while being 'part of the solution' to the obesity crisis. These types of PPPs could negatively affect populations and governments.
Advocates, policymakers, and health professionals should be aware of these risks when considering partnerships with the F&BI.

## Introduction

The United Nations (UN) and the World Health Organization (WHO) have recommended Member States build strong coalitions as a key ingredient for tackling non-communicable diseases (NCDs) through policy change.<sup>1-4</sup> This mandate is also part of other international obligations and recommendations such as the Sustainable Development Goals (SDGs), in particular SDG#17 on partnerships, and the UN Decade of Action on Nutrition.<sup>5</sup> Given the lack of resources and state capacity in several low and middle-income countries, public-private partnerships (PPPs) and multistakeholder arrangements (MSAs) have recently been seen as key collaborations towards building strong coalitions, as means of implementing programs and achieving public health goals. PPPs and MSAs constitute a hybrid type of governance in which non-state actors (e.g. corporations) co-govern along with state actors to provide collective goods. These partnerships thereby adopt governance functions that have formerly been the sole authority of sovereign states.<sup>6</sup> This transition from primarily public to a primarily public-private form of governing raises important new theoretical and political concerns of legitimacy<sup>7</sup> and challenges existing conceptualisations of regulation.<sup>8,9</sup> The increasing prominence of such arrangements<sup>10-13</sup> raises questions about the identification and management of potential tensions between private partners and public health. PPPs and MSAs with unhealthy commodity industries, including the food and beverage industry (F&BI), have been shown to protect the industry's economic interests more than promoting public health.<sup>14</sup> PPPs and MSAs can neutralise the actions that public interested groups and governments might develop to improve public health policies.<sup>15-17</sup> For instance, the involvement of commercial actors in multistakeholder consultations is likely to delay efforts to develop coherent political commitments to addressing the structural drivers of NCDs and other nutrition and food-related policy efforts.<sup>11</sup>

Evaluations of PPPs in the field of public health nutrition have shown how the power of private partners exceeds those of others involved and facilitates these private entities to pursue business interests within the public health policy agenda. The F&BI acts as a legitimate participant in committees or advisory boards of health government agencies and has been seen as a legitimate partner for interventions aimed to improve community health,<sup>18</sup> access to food or water, or promote behavioural change.<sup>19</sup> However, there is also an increased
recognition in the literature that the health agenda is so complex that no single sector or
organisation can tackle it alone.²⁰,²¹ While some authors have identified the limitations of
hybrid governance, others argue that the complex agenda of NCDs requires a range of
responses beyond the capacity of either the public or private sectors working independently,
and therefore relationships need to be built between them.²²

PPPs are one of the many mechanisms of engagement between corporations, including
transnational F&BI and different government agencies. PPPs have been classified as an
instrumental action in relation to other tactics to obstruct or delay public health aims.²³,²⁴
Nevertheless, the transnational F&BI influence on the delivery and results of the programs
delivered through PPPs is yet to be fully explored.²⁵

Public health interventions and public-private partnerships in Mexico

In Mexico, the prevalence of obesity in adults is 75% and more than 35% schoolchildren are overweight, as rates of diabetes continue to escalate.⁴ Obesity was declared a national public health emergency in 2016, and again in 2018.²⁶,²⁷ More than 250,000 people die each year from causes related to NCDs, including heart disease and diabetes.²⁸ These public health issues and changes in the countries' obesity policy agenda have led to the proliferation of public policy actions and the implementation of programs to reduce NCDs with population interventions. Some of these interventions are outlined in the 2013's National Strategy to Prevent and Control Overweight, Obesity and Diabetes (ENPCSOD) and have become opportunities for private entities to be 'part of the solution' to addressing the obesity problem.¹⁴,²⁹ As such, PPPs between the transnational F&BI (hereafter F&BI or 'the private partner') and different government agencies have been prevalent in Mexico. While some PPPs with the F&BI have existed for a long time, others have emerged in response to the government's strategies and policies aimed at tackling obesity³⁰, such as an weak industry-led front-of-pack nutrition labelling (FOPNL) policy. This study analyses how four PPPs between the Mexican government and the F&BI and allies are working to achieve their goals. We focused on four PPPs that aimed to control obesity, increase physical activity levels, and improve access to drinking water and sanitation. We critically assess these four PPPs' objectives, scope, reported impacts, governance principles and perceived risks and benefits.
## Methods

This is an exploratory study using a documentary analysis and interviews of four PPPs in Mexico. We selected four PPPs (listed in Figure 1) purposely following a series of criteria described in Figure 1 and, after conducting a literature review.³¹ The selected PPPs aimed to provide a service or a program in the country, functioning as partnerships in policy implementation targeted at vulnerable groups, and include children and low-income populations. The cases included partnerships either that started while or after ENPCSOD was negotiated (2011-2012) and until 2019, when we started this study.

We critically examined these PPPs by analysing public documents and conducting key informant interviews to compare the information provided by the private and public partners for each program. First, we used the Logical Framework Approach (LFA), a methodology mainly used for designing, monitoring and evaluating projects, to understand the goals, objectives, outputs, and activities (implementation) of each PPP.³² We also applied this approach to understand each program's indicators for monitoring their implementation and evaluating their impact³², as the LFA helps to articulate a common interpretation of the objectives of a project and provides a clear basis for monitoring progress and verifying achieved objectives. While we did not aim to map all the components of each PPP in our study, we used the LFA to identify the clarity and transparency of their objectives, outputs, and activities.

Secondly, we assessed the governance principles followed by the partners in arranging and executing the PPPs. We used the principles of good governance previously described in the literature ²⁵,³³,³⁴ to assess each PPP (Figure 3). These principles have consistently been used to assess health programs and interventions by intergovernmental bodies and public health research.³⁴ For this study, we determined that gaps in any of the information given by the documents and interviewees might imply weaknesses of the governance principles. Finally, we analysed the perceived risks and benefits of each PPP, the actors involved, and their relevance to the nutrition policy agenda.

<caption>[Figure 1 Inclusion criteria of PPPs selected for analysis]</caption>

### Data selection

We conducted a document review related to the selected PPPs and the Mexican context (documents published between 2012 and 2019). We first performed an initial search between February and March 2020 using Google and Google Scholar with key search terms outlined in
Figure 2. We then used the snowballing technique and conducted a forward search for documents that cited previously identified sources. We also made 50 freedom of information (FOI) requests to different national and sub-national government institutions involved in the PPPs of study. Of these, 22 official documents were obtained. We contacted the Secretaría de Salud (SSA), Secretaría de Educación Pública (SEP) and the Instituto Nacional de Infraestructura Física Educativa (INIFED). We also contacted the local subsidiaries within Mexican states where the PPPs operated and were promoted. Overall, a total of 170 documents were identified for our analysis, including industry annual reports, civil society group websites, press releases or reports, journalistic notes, and FOI official documents.

The first and second authors conducted 26 semi-structured interviews with purposively selected key informants from March 2020 to June 2020, after inviting 41 people identified through the documentary review and using the snowballing technique. The sample included a variety of actors: seven experts on PPPs (academic or international organisations), eight operational personnel or consultants for the PPPs studied, five civil society members or foundations' representatives, two private sector representatives, and three government representatives familiar with the PPPs included in our study. The interviews were conducted during the Covid pandemic, so several interviewees were either not available to participate (n=4), did not respond (n= 9), or declined to participate (n= 2). Saturation was reached when similar themes emerged. The interviews lasted between 40 to 60 minutes and followed a semi-structured interview guide covering the origin of the PPP, their purpose, operations, evaluation and monitoring, brand and company associations, and perceived benefits and weaknesses (Supplementary material 1). The guide was informed by selected literature on good governance and the LFA (Supplementary material 1).

Ethics approval was obtained from the Comité de Ética en Investigación Instituto Nacional de Salud Pública on March 2, 2020.

**[Figure 2. Key terms for searches]**

**Analysis and synthesis**

The interviews were transcribed verbatim, and the transcriptions and documents selected were analysed thematically. The research team followed an initial coding framework based on our research questions and informed by the select literature on good governance and the LFA (Supplementary material 1). The framework was discussed and further refined by the team in an iterative process. AC and EO coded five transcripts, after which the framework was
adapted and applied to all transcripts and documents using NVivo 11. Codes were checked
between the researchers to ensure accuracy and coherence. Two co-authors (AC and EO)
reviewed 10% of the codes for consistency and reliability purposes (>0.75 Kappa value).
Authors held regular discussions, which allowed reflexivity and discussion of potential biases
on the analysis due to coders' role in the topic, familiarity, and beliefs about it. The analysis
was conducted between June and December 2020.

The theoretical perspective was underpinned by a 'realist' or 'contextualist'³⁵ view of the data
as representing individuals' intersubjective meanings within a socially and materially
structured (real) environment. As a result, we cannot fully know the 'truth' of a situation, but
we can get closer to it through methods such as listening to and triangulating the views of
people who experienced it.³⁶

We present our qualitative synthesis by topic themes grouped into a) the programmatic
aspects of the PPPs, based on the LFA components used for the interviews and coding, and
b) principles of good governance (described in Figure 3) in the PPPs.

<caption>**[Figure 3. Definitions of good governance principles applied to the analysis]**</caption>

<caption>**Figure 3. Definitions of good governance principles used for the analysis**</caption>

**Accountability:** Decision-makers in government, the private sector and civil society organizations involved in health are liable to the public, as well as to institutional stakeholders. This accountability differs depending on the organization and whether the decision is internal or external to an organization. ³⁴

**Credibility:** It includes trust and trustworthiness. Trustworthiness relies on the institution and on the perception the public has of the institution. (Marks, 2019)

**Efficiency and effectiveness:** Processes and institutions should produce results that meet population needs and influence health outcomes while making the best use of resources³⁴

**Ethics:** The commonly accepted principles of PPPs include beneficence (should lead to public health gain); non-maleficence (must not lead to ill-health); autonomy (should not undermine each partner's autonomy); and equity (benefits should be distributed to those most in need).

**Fairness:** is characterized by equity, respect, justice and stewardship of the shared goods, both among people and in their relations to other living beings.

**Integrity:** Integrity exists when there is consistency "*among what an institution does, what it says it does and what it is obliged to do*" ³⁷(p. 115). Consistency is needed between the practices, its mission and its purpose.
**Participation:** All men and women should have a voice in decision-making for health, either directly or through legitimate intermediate institutions that represent their interests. Such broad participation is built on freedom of association and speech, as well as capacities to participate constructively. Good governance of the health system mediates differing interests to reach a broad consensus on what is in the best interests of the group and, where possible, on health policies and procedures.³⁴

**Stewardship:** It is defined as the function of the government responsible for the welfare of the population and concerned about the trust and legitimacy with which its activities are viewed by the citizenry ²²,³⁸,³⁹

**Transparency:** Transparency is built on the free flow of information for all health matters. Processes, institutions and information should be directly accessible to those concerned with them, and enough information is provided to understand and monitor a health matter.³⁴

**Conflict of interests:** (COI): arises in circumstances where there is potential for a secondary interest (a vested interest in the outcome – of the programs) to unduly influence, or where it may be reasonably perceived to unduly influence, either the independence or objectivity of. Professional judgment or actions regarding a primary interest (in this case the program to be delivered)⁴⁰

## Results

The details of the four PPPs studied are presented in Figure 4. This includes the partners involved, the geographical area they operate in, the name of the program given by the private and the public partners (which can differ), and the project aims, the beneficiaries, and their potential impact.

**[Figure 4. PPPs studied, the private and public actors involved, aims, beneficiaries, and potential impact]**

Our findings suggest that the main instruments used to consolidate the partnerships were written agreements between the government (either with local or federal authorities) and an organisation sponsored by the F&BI or directly with the company's philanthropic foundation.

**Three** partnerships were announced in public gatherings by local or federal government officials and outlined in corporate reports, but we could not find accurate information available on the engagement from government FOI replies.
**1.1 Types of PPPs identified**

We identified three types of arrangements between the public and private sectors. The first type is when the private sector joins a public action (program), typically only for a specific part or during the implementation phase, which is often restricted to donations (e.g. *Centros de Hidratación* and *Ponte al 100*). The second one identified was when the private sector presents its own program and the public partner had little influence on its design but had the freedom to implement it, either to complement a program already running or to start a new one (e.g. *Agua Saneamiento y Salud*). The third type was when the private sector leads, designeds, implements and acts as the decision-maker of the PPP. While the government provides access to the venues, the private partner implements the program in various settings, such as community centres, municipality government offices, schools, or community centres (e.g. *Nestlé por niños saludables* and *Centros de Hidratación*).

**1.2 Programs' aims, objectives, design and implementation**

When studying the aims, objectives, design and implementation of the four PPPs studied we found: i) in some cases there were key discrepancies between the aims described by different partners involved (either documents or verbally described by interviewees); ii) uncertainty about the delivered actions, scope of the intervention and benefits to the population; iii) unclear information about the indicators, or existing evaluations of the PPPs and their overall impact on health outcomes. Figure 5 provides examples of the how different sources describe the objectives, actions, indicators, goals and (or) impact of the PPPs.

[Figure 5. Examples of objectives, actions and indicators described by the private partner (or through the front groups) and by the public partner in the various case studies.]

For the program Ponte al 100, different objectives were reported by each partner (see Figure 5). While Fundación Movimiento es Salud A.C., the association funded by Coca-Cola aimed to assess the 'physical capacity -without a clear definition of what that means- of schoolchildren', the government stated it was a program 'to improve physical activity among schoolchildren and their families'.

The program Ponte al 100 started in 2013 as a pilot in the State of Mexico and it became part of the national program of physical activity and the National Commission for Physical Culture and Sport (CONADE), and the Secretariat of Health (SSA) and Coca-Cola. As one informant
described: 'Ponte al 100 is basically the set of tests to measure physical activity capacity' (Civil society representative), and confirmed that the aim of the program was adapted to fulfil the request of the SSA to enable the partnership at the federal level: 'We changed the original objective [note: participant did not provide information on original objective] and converted it into a physical activity program, aiming to make people healthier. I had the first permits from the SSA [to operate in schools at the time]. We sought authorisation with Mercedes Juan [the Secretariat of Health]. Pablo Kuri [the Under Secretary of Health] didn't like the program because we were not a [obesity] preventing program as it is strictly defined in the NOM-008 for obesity prevention'. (Civil society representative)

The General Law on Educational Physical Infrastructure proposed 'to install drinking water fountains in public schools, from preschool to high school' (La Jornada, November 13 2013). According to the law, the aim was 'to benefit 242,621 schools reaching 30, 115, 977 students in the national education system', where the 'private partner will support the instalment of the fountains.' In 2015, INIFED was appointed to provide schools with water fountains as part of the 'Programa de Reforma Educativa' following the approval of the law. It was a program aiming to improve the schools' infrastructure and, overall, the education system in the country. Escuelas Sustentables A.C., funded by Fundación Coca-Cola, had a slightly different aim, which was to provide drinking water to communities and promote responsible use of water. In the agreements we reviewed (obtained through FOI requests) Escuelas Sustentables A.C. agreed to provide support to install and evaluate the water quality and access to clean water. Also, it committed to providing guidance and training to manage and maintain the water fountains and requested the government that for each water fountain it installed, the government should install one with public funds. The agreements also mentioned that the F&BI (and not the foundation) be acknowledged for this work; hence the installation would carry the name of a soda company, a form of branding beneficial to the industry:

For the program *Nestlé por niños saludables*, the public partner framed the PPP as 'promoting knowledge in school-aged children', while Nestlé, the private partner, reported that the main aim was to develop material and make it available to teachers to promote healthy habits among schoolchildren (Figure 5). This limits the private partner intervention in the program to facilitate educational materials, which the public partner must deliver to teachers and students.
**Uncertainty about the actions, scope, and benefits of the intervention**
**Information management and implementation**

Information management was also unclear for some of the PPPs. Private partners reported having records and results but mentioned they were not publicly available or were not shared with our research team. For the public entity, operating rules of public programs exist, but some of them were written a posteriori,⁴¹⁻⁴⁴ were not appropriately followed,⁴⁵ or in some cases, as some FOI responses indicated, were non-existent. Some indicated that another authority was responsible for it, but none of the submitted FOIs yielded relevant information despite the requests being made to various institutions at national and local levels. Some public entities either delayed or denied answering us. In some cases, they pointed out that it was the responsibility of the private sector, as shown in Figure 6, without it being. The fact that the private sector held records of the program's implementation, beneficiaries' records, and details on indicators of impact was not perceived as a conflicting issue.

<caption>**[Figure 6. Examples of FOI answers for Centros de Hidratación and the agreements with Fundación Coca-Cola]**</caption>

**Program indicators, monitoring and evaluations**

The studied PPPs' indicators for activities, outputs, or programs' impact were not clear in the private or public partners' documents. For instance, *Ponte al 100* provided information on how many 'functional capacity assessments' were conducted (outputs of the intervention). Coca-Cola's 2015 annual report mentions that *Ponte al 100* performed personalised diagnoses on 1.6 million Mexicans, and in 2016, on 2.6 million people. But CONADE reported a total of 1,364,891 'functional capacity' assessments during the operation of the program-from 2013 to 2015 (CONADE Reply to Senators, December 6, 2017, and FOI given by CONADE, October 2020). Nevertheless, it did not provide how many or, if at all, people changed their physical activity patterns or improved their diet (outcome).

For *Nestlé por Niños Saludables*, we found similar issues, with interviews from the private partner mentioning there were in-house reports on the progress of the program, and a press release by Nestlé stating that 'The program has shown that children have increased their consumption of vegetables and fruits, in addition to increasing their physical activity', but with no specific data or ways to verify of such claims.⁴⁶

Likewise, *Centros de Hidratación* outlined indicators to measure progress, with the number of water fountains installed, but it was unclear how these changed the drinking patterns for
children and therefore improved health (the impact the national program claimed to be aiming for).

For *Agua Saneamiento y Salud*, PepsiCo reported that their donations to IDB provided new or improved access to safe water and sanitary services to more than 765,000 people (PepsiCo Sustainability Report 2018), while the IDB provided the 'number of homes with improved access to drinking water as 4,000,000 in 2018' (IDB Press Release, 2014) and to have reached a total of 772,181 persons (Figure 4).

## Impact and effectiveness of the programs

In terms of evaluation and effectiveness (as defined in Figure 3) of the program, we found that there were three evaluations done, one each for *Centros de Hidratación, Ponte al 100* and *Agua Saneamiento y Salud*. Despite all of them being from external evaluators, there were inconsistencies with the results reported by the private sector. For example, while the private sector entities reported on achievements (impact), the public sector reported on the goals, not on the impact of the interventions. None of the four PPPs studied had public access to complete information on the impact evaluations of the programs.

## 1.3 Governance

The principles of good governance as defined for this paper (see Figure 3) were not reflected in the information gathered from the programs, including those of accountability, transparency, fairness, participation, integrity, and credibility.

## Accountability, transparency, and credibility

Considering the areas of interaction, confrontation, and synergies between public and private actors, we found that public figures with political ambitions, such as governors, communicated openly about their interactions with soda companies or their subsidiaries. In the same way, the soda companies framed the cooperation with local governments and their common social goals as part of their 'corporate social responsibility'. For example, a Coca-Cola report states, 'The Coca-Cola Foundation joined forces with the National Commission for Physical Culture and Sports (CONADE) and the Secretariat of Public Education (SEP) for the implementation of 'Ponte al 100.' (Informe de sustentabilidad, Industria Mexicana de Coca-Cola, 2014 p.19) However, the clarity of the private sector involvement became less clear in the most recent corporate reports reviewed 47-52, which describe the PPPs as part of their CSR actions with a
glimpse of information on their web pages and charitable branches. At the federal level, reports do exist but leave most of the information, indicators, results, and impact quite unclear, as described above, calling into question transparency, accountability, and stewardship issues.

Some confrontations between the public and private actors were perceived through the history of each PPP studied. For *Ponte al 100*, the discussion about accountability generated a clear conflict for the program and for the PPP. In September 2016, Senator Martha Tagle Martínez filed a petition to CONADE for getting information about the details of the program, including all the names of the governmental and non-governmental organisations and the contribution of each one to the program. She presented the budget assigned to this program in 2013 and in 2014 and questioned how this was spent, arguing that 'an official registration of the program is inexistent,' the program 'left financial damage while Mena was the head of the CONADE,' and that 'some of the problems this program had were discussed in the Semanario Proceso' where 'accounts about the delay and the lack of transparency is investigated.' The senator pointed to the discrepancy about the participation of Coca-Cola in providing materials and equipment for the execution of the program. The senator also discussed the expenditure of money for that matter, on the open tenders, duplicated expenses, and doubts about corruption around the program's finances. Additionally, compared to its launch, when the PPP was applauded by many politicians, by the end of it, the PPP was highly criticised by many scholars because of its ineffectiveness in reducing childhood obesity.⁵³

We learned that the program *Nestlé por Niños Saludables* will continue in the State of Veracruz until 2024. Also, Fundación Movimiento es Salud was still operating *Ponte al 100* as of November 2022, when we conducted the study, but as a program called *Prospectiva 2030* in 5,000 schools. We obtained one 2018's agreement, signed by the State of Campeche public authorities, stating that the program aimed to 'follow up the schools for three years'. Only one government official mentioned this information and clarified that although they were trying to stop this partnership in the State of Yucatán, it was still running in other states, and it was up to the local authorities to accept it. In the case of *Agua Saneamiento y Salud*, the involvement of the soda industry is not obvious and has not been recognised in any document, a clear issue with transparency. For example, for *Agua Saneamiento y Salud*, none of the documents mentioned any potential 'risks' given the conflict of interest that promoting and managing access to drinking water to small populations implies for soda companies. Indeed, some community activists pointed out that the PPP is strategically executed in places where
the same soda companies have their bottling plants and added *that* 'a bilateral organisation carries out the management of the program, so the visibility of the participation of the private sector is diluted,' (member of civil society).

**Ethics, integrity, participation, fairness, and stewardship**

The PPPs studied were unclear on their ethical principles, such as involving no harming principles, being directed to people, and respecting autonomy and equity. Although non-governmental organisations financed by the private sector declared corporate values and missions on their webpages, principles to achieve these mission statements in the four PPPs were not established in the accessed agreements or evident in their execution, as reported by our interviewees.

Integrity (as defined in Figure 3) was also at stake in some cases. A clear example of this discrepancy was found through the FOI requests for the program *Nestlé por Niños Saludables* in the State of Mexico. The private entity mentioned that 'For 13 years, Nestlé por Niños Saludables has been successfully implemented in different parts of the country, impacting more than 4.5 million children, in more than 6,000 public and private schools in the country with a special focus on Mexico City, State of Mexico, Guanajuato and Veracruz' (Press release by Nestlé, 14 March 2019). Meanwhile, the public entity, the education authority of the State of Mexico, replied to our FOI request, saying that 'after a meticulous search in the archives of this Administrative Unit, these documents are not available' (Response of the Secretariat of Education of the State of Mexico, 2020).

Both *Nestlé por Niños Saludables* and *Ponte al 100* were granted access to children's records (including the personal information of thousands of children and students). Data protection of participants was not mentioned in any of the agreements reviewed or in any of the interviews conducted, but the PPP agreement mentioned that Fundación Movimiento es Salud A.C. had to keep data confidential.

As with the principles of stewardship, fairness, transparency and accountability, we found that each of these programs has been subject to criticism. Some Congressmen or public-interested groups through the media made strong calls for better accountability.⁵³,⁵⁴

**Conflicts of interest**

CoI are not part of the good governance principles as defined in the existing literature, but represent a key issue encountered in PPPs, particularly the institutional CoI involved in such
arrangements. According to the definition of CoI we used (see Figure 3), in all PPPs, the CoI for the public partner was inherent. The transnational F&BI involved in the PPP's core aim was to improve their profits by selling their products. The portfolios of products of the F&BI participating in the studied PPPs were mainly composed of ultra-processed foods or beverages high in sugar, salt or fat. Thus, their primary activity went against the government's duty to protect and promote public health.

The public partner's employees in the PPPs, both those working in the field directly with beneficiaries and those at the coordination level, were largely unaware that the programs had private partners or that the public sector made commitments to the private sector.³⁷ For example, for *Centros de Hidratación*, an interviewee mentioned, 'The only one who knew who the sponsor was, was the school director, and he decided if it had to be known by the parents or not.'

Some of the interviewees did not consider PPPs with F&BI to be a CoI. However, some of the agreements include clauses requiring the public sector to mention, acknowledge, or label program material with trademarks. For example, this included naming Coca-Cola on a silver plate next to the water fountains or using Nestlé logos on the material provided. Likewise, implementers mentioned that brand promotion at the sites where the programs were implemented was present either in a subtle (e.g. brand colours) or in an obvious way (e.g. logos), but neither the interviewees nor the beneficiaries considered them as relevant or inappropriate.

Some of the public actors interviewed did find it difficult to understand and to accept industry collaborations, and they mentioned that they have tried to change the behaviour of local authorities around CoI, but sometimes, further up in the power chain of actors, relationships with the F&BI prevail and are 'untouchable'.

## Perceived risks and benefits

Some experts and implementers interviewed perceived risks associated with PPPs because of the potential lack of continuity of the programs and their 'negative impact on public health' (Expert). One expert noted that there was a lack of understanding among public servants that philanthropic organisations involved in PPPs are in fact third parties for the F&BI. As an expert noted:
'On multisectoral governance, it looks great to involve civil society; the problem is what kind of civil society participates because when you see in detail, they are NGOs sponsored by the F&BI' (Expert).

Other risks associated with these PPPs were related to tax deductions for philanthropic foundations, as an expert suggested:

'The tax exemption generates a structure to create a bureaucracy for tax deductions. The moment it [the tax exemption] is given to the private [partner], they are no longer public resources [and], a problem of accountability emerges, it [the private partner] is not being held accountable, or we ignore if children [beneficiaries] improved [their habits] or not' (Expert).

Despite some of the risks and limitations of programs executed by the government in collaboration with the F&BI, as described by a public official, there was 'the sense of a financial relief for a stretched [public entity]'. Nevertheless, we found that public officials were less inclined to recognise that interactions with the private sector might influence their own institutions' policies and practices. As mentioned by an interviewee:

'In Monterrey, Fundación FEMSA work on the water looks great because they're from Monterrey, and it's almost a source of pride, and they have a good water system... Instead, Coca-Cola in San Cristóbal had to negotiate a lot; they were perceived as the bad ones' (IDB informant).

Likewise, the technological and practical knowledge of the private partners was also seen as a benefit because 'they know what they are doing in the field' (civil society organization) and as mentioned by one informant: 'disclosing the relationship with the private partner [to beneficiaries] is not relevant' (government official), arguing that having corporate support is better because 'otherwise it wouldn't be provided'.

## Discussion

In this study we analysed how four PPPs between the Mexican government and the F&BI and allies are working to achieve their goals. We focused on four PPPs that aimed to control obesity, increase physical activity levels, and improve access to drinking water and sanitation. We critically assess their objectives, scope, reported impacts, governance principles and perceived risks and benefits. We found that among the PPPs studied, there has been a lack of synergy between the goals, aims and actions of the public and private partners involved in delivering the intended benefits through their programs. The aims diverged as there was no
clear information on the execution of the programs conducted under the PPPs and little details about their results or impact on public health outcomes. Some of these programs have been evaluated by external parties, but the results did not coincide with the initial aims or goals originally established, therefore making it impossible to understand if these PPPs were effective in contributing to the public health agenda of preventing NCDs. We found issues with accountability, transparency, and credibility, as well as ethics, integrity, participation, fairness, and stewardship, a finding that is aligned with what other authors have previously found and discussed in the literature.²⁵,³⁷,⁵⁵,⁵⁶

This study adds to evidence that PPPs raise concerns about how effective they are in contributing to the public health agenda (framing effects, influencing the agenda, reporting results, etc.). Although PPPs in Mexico might sound commendable, there is little evidence that the partnerships achieved what policymakers hoped and what the local populations might have expected. The efforts to address obesity or access to water, through tailored programs run by PPP arrangements studied here have failed to show an effect on the population's health, mainly because there are no, to our knowledge, clear indicators or impact evaluations available. If there are indicators, they were not consistent within partners or have been found to be inefficient and poorly executed. In the past couple of years, scholars and activists have suggested mechanisms for accountability, ethics and transparency on PPPs, so they could be either modified or avoided.²⁵,⁵⁷⁻⁵⁹ Also, typologies of PPPs have been suggested to try to improve accountability and transparency of their governance.⁶⁰

This study also sheds light on the advantages and importance that filing FOIs has for methodological and health policy research and to investigate transparency and accountability. Our findings suggest that public officials are less inclined to recognise that interactions with the F&BI or their allies might influence their own institutions' policies and practices. For years, activists have been concerned about the political influence of the F&BI in the country.⁵⁶,⁶¹ Still, people executing programs, bureaucrats, and beneficiaries rarely consider engaging with the F&BI for public health issues, mainly aiming to deliver programs to children, as problematic. —Nevertheless in the past three years, some efforts to reduce industry interference in food policy making are emerging in Mexico due to the unprecedented exhortations by the Human Rights Commission to protect children or the intersectoral GISAMAC initiative promoting new legislation on healthy eating.⁶²

Although there have been concerns about PPPs for many years among scholars, public servants, and activists,³³,⁶³ no clear guidelines exist on how to face the CoI and governance
issues in these arrangements. The existing ones are either published in collaboration with representatives of the food industry or are general guidelines for any type of engagement with the F&BI and with the tobacco industry.⁴⁰,⁶⁴⁻⁶⁶ The use of core principles and practices of good governance is a way to move forward to identify the benefits and risks of PPPs. Likewise, when information is available, the use of the logical framework to identify information and key factors of any public program that should be available to the population (either on the institutional websites or if requested) might be helpful to improve the accountability and transparency of PPPs.

PPPs are permanent in many settings but take more complex forms with F&BI participation through the third parties that they fund.⁶⁰ However, the links with the industry are not made clear despite, in many cases, having a transparency platform that citizens can use, particularly in low-resource countries, making it more difficult for policymakers and participants to perceive them as originating or being developed in collaboration with commercial actors. PPPs are endemic, and, in some instances, they might still be a good way of financing public health initiatives. For the type of PPPs studied here, the involvement of alternative industries other than the F&BI could serve as a solution to avoid institutional conflicts of interest, promotion of harmful products, or breach of key principles of health governance in PPPs.²⁵,⁵⁹ Nevertheless, this will not be sufficient to change the problems that these PPPs have on transparency and governance unless they are accountable to third parties from their conception to their execution and results. As our results show, the lack of clear results on effectiveness was highly criticised and resulted in a lack of trust in public institutions. Our results show that governments aiming to advance the health agenda might benefit from preserving their independence, integrity and, therefore, credibility. As shown in this study, the private sector uses the public sector as a vehicle to reach the population they want and to set their own agenda, promoting their brands in attempts to keep loyal consumers.

Even with the current strong mandates of the new Mexican government to avoid having formal relationships with the F&BI (at least at the Federal level under the SSA), there is still a need to further understand PPPs moving forward, given the power the F&BI has in the political and the economic situation of the country. It is essential that the academic community and public health advocates be vigilant and claim transparency of such partnerships, and advocate for them to end where necessary.
## Limitations

Whilst this study was designed and implemented using best practices available to us to address the study's aims, we acknowledge the following limitations. First, by looking at individual PPPs in isolation, we may have neglected the cumulative and synergistic effect of PPPs, regardless of some of these being ethically problematic. Second, we collected data prior to and in the middle of the COVID-19 pandemic when global public health issues and challenges were occurring, thus limiting the availability of informants and responses from the government officials. This might have affected some views and answers of interviewees. Third, we had difficulties in tracking the information on PPPs, as there was no consistency in naming, reporting, monitoring, or talking about said PPPs. For the sake of this study, we used the title as we first encountered it in the literature and triangulated data, although it might have changed through time or by the time this paper is published. Finally, we acknowledge that the authors' interest, nationality, and our expertise on the corporate political activity in Mexico's food policy might have influence the interpretation and assumptions on this exercise. Nevertheless, transparency on data collection and the analytical framework outweigh such limitations and supports the reliability and replicability of this research.

## Conclusion

At both national and sub-national levels, the four PPPs studied in Mexico were found to have minimal public information available on their implementation, impact, or effectiveness in contributing to the public health agenda. The F&BI partner tended to dictate the design, information management, and implementation while promoting their brands through the partnerships. Few independent evaluations of the PPPs exist, and none reported on the effectiveness or relevance to public health. Good governance principles, such as accountability, transparency, fairness, participation, integrity, and credibility, were barely followed in each of the cases studied. COI in such arrangements has not always been questioned by public officials, and if so, the risks of such PPPs did not always outweigh their financial benefits. This study shows that these PPPs produced minimal gains for public health while boosting the credibility of the participating transnational F&BI partners.

## Ethical issues

National Institute of Public Health Nutrition Ethics Committee, Cuernavaca, Mexico.
## Acknowledgements

We would like to thank Jonathan Marks, Claudio Shuftan and Margaret Miller for their valuable comments and suggestions to the project which this publication is based on.

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