Methods for evaluating efforts made by governments to prevent and mitigate corporate influence and conflicts of interest in public health policy

Introduction

Corporate influence on public health policy is widespread and increasingly well-documented across the globe^1–3. The tobacco, alcohol, food, and pharmaceutical industries have long-established relationships with health professionals and scientists, shaping information and evidence around the harmfulness or healthiness of their products – information that is then used in policy-making and for marketing purposes^4,5. Lobbying and political donations, amongst other political practices of corporations, are also prominent in the alcohol and gambling sectors^4,5. That influence from corporations on public health policy varies by industry, but is particularly problematic in the case of corporations whose practices and/or products are harmful to health, such as the ultra-processed food³, alcohol³, tobacco³, gambling^6,7, oil^8,9, opioid¹⁰, and pharmaceutical industries¹¹. Industry influence on public policy could delay, weaken, and avoid the adoption of measures that would protect and improve population health³. Financial conflicts of interest (COI) are also problematic in policy-making at the individual and institutional levels because they may compromise decision-makers’ loyalty or independent judgment¹².

Evidence suggests that public opinion is in favor of preventing and mitigating influence from corporations and COI in public health policy, particularly in the case of health-harming industries¹³. A recent scoping review identified existing mechanisms that could be adopted by governments with that purpose¹⁴. These mechanisms include: i) transparency and disclosure of industry influence and COI (e.g., a register of lobbyists); ii) identification, monitoring, and education (e.g., awareness-raising activities for decision-makers about a given industry, its products, and practices); iii) management (e.g., guidelines for the receipt of gifts and donations, regulation of lobbying and political finance and elections campaigns); iv) prohibition (e.g., mandatory waiting periods to work in the industry after the termination of employment in government)¹⁴. Other mechanisms include the protection of whistleblowers or the adoption of a national health plan or strategy that explicitly includes the protection of public health policy from industry interests¹⁴. In total, there are twenty-three mechanisms that governments could implement to help prevent and mitigate the negative influence of corporations on public health policy (see the Extended Data for a full list of such mechanisms for governments¹⁵).

From a human rights perspective, governments are obligated to protect and promote the health of their citizens¹⁶, including children, which inevitably includes the protection from actors (i.e., corporations) that harm health^17,18. Transparency and disclosure are often prioritized by governments when trying to prevent and mitigate the influence of corporations and COI on public health policy, but scholars have argued, based on empirical evidence, that while these mechanisms are necessary, they are far from sufficient to address the issue systemically^19,20. Krimsky, Bero, Goldberg, and Marks, for example, call for the prohibition of COI, since a COI is already existing by the time it is disclosed, and transparency could not prevent that COI and resulting potential bias to happen^19–22.

However, there is little knowledge on the progress made by governments to adopt the above mechanisms. Evaluating that progress for a given country over time is also important. We, therefore, build on the existing scoping review cited above¹⁵ and propose methods for evaluating the progress made by governments for the implementation of those 23 mechanisms. This will help countries systematize their efforts, benchmark their progress internationally, and give perspective on particular weaknesses, approaches, and investment gaps needed for change. The methods we have developed are primarily targeted at researchers and civil society organizations interested in assessing the efforts made by governments in protecting public health policy from undue corporate influence and COI. However, government stakeholders can be included in the evaluation as observers for transparency reasons and to catalyze change.

Methods and expected results

Here, we propose new methods for evaluating the efforts made by national governments in implementing mechanisms to prevent and mitigate corporate influence and COI in public policy. Our methods are informed by the Healthy Food Environment Policy Index (Food-EPI), an index that assesses the implementation level of policies to help prevent and control diet-related non-communicable diseases by national governments²³. Among the 47 Food-EPI good practice indicators, one indicator assesses, in a general way, whether governments are putting robust procedures in place to restrict corporate influence on the development of public policies²³. The Food-EPI has been conducted in about 40 different countries across the globe²⁴. We propose an innovative application of the Food-EPI, with our aim being fundamentally different, as we focus here on corporate influence and COI in public health policy, rather than food environments more broadly. This therefore involves a different set of mechanisms than those covered by the Food-EPI. We also do not focus on the food industry here, but corporations and COI more broadly.

Our evaluation comprises five steps, described below (Figure 1): 1) Gathering information about the national context; 2) Gathering evidence on the implementation of mechanisms by national governments; 3) Verification of step 2 by government officials and policy experts and local public health experts; 4) Identification and prioritization of actions in a workshop; 5) Supporting the translation of findings into policy actions.

Figure 1. Steps for evaluating a government’s progress in implementing mechanisms that could help to prevent and mitigate corporate influence and conflicts of interest (COI) in public health policy.

Discussion

The proposed evaluation aims to help governments systematize their efforts and give perspective on particular weaknesses in their adoption of mechanisms that could help prevent and mitigate undue influence of corporations and COI in public health policy, particularly from industries whose products and/or practices are harmful. We suggest that the methods be used at the country level. We will implement and validate the proposed methods in Ireland as a first case-study in 2024-25.

An evaluation of the progress made by governments for the implementation of mechanisms over time will be possible, as the exercise proposed here aims to generate policy actions towards the implementation of these mechanisms. Comparison and benchmarking of governments will also be possible when the evaluation has been undertaken in different countries.

The evaluation is meant to be applicable in the case of public health policy, but many of the mechanisms to prevent or mitigate corporate influence and COI in public policy, as described in Mialon et al.¹⁴, are not specifically targeted at public health. Hence, it is likely that the proposed evaluation could be applied by researchers and advocates working on other issues such as climate change or social inequities.

There are some foreseen challenges in undertaking the evaluation. First, we propose to establish contact with government officials and policy experts and local public health experts. Those individuals have busy schedules and may have limited time to participate in the evaluation. To overcome that barrier, we recommend that researchers undertaking the evaluation rely on their professional networks. Moreover, those unable to participate in the evaluation could also be asked to recommend someone else who may be able to contribute. Another challenge for the proposed evaluation is the fact that new mechanisms will likely be identified in the future, as knowledge in the field progresses. Certain mechanisms might also be removed from the evaluation if they are proven to be insufficiently effective. Therefore, the criteria for evaluating the progress in the implementation of mechanisms and for benchmarking national governments will change over time. As research in that space progresses, mechanisms for addressing undue corporate influence and COI in public health policy will be further studied. The proposed evaluation could therefore assign higher or lower importance to particular mechanisms, for their relative effectiveness.

We anticipate some resistance in translating the findings from this type of evaluation into policy actions. It might be the case that the most important mechanisms to implement in a given country, as identified in Steps 4 and 5, are also the most expensive to put in place. Or that the least accepted mechanisms are more effective than those that are more accepted. As we had noted earlier, some governments with a low state of democracy might not be willing to implement certain mechanisms. Finally, corporations whose political influence will be limited by the implementation of mechanisms proposed by Mialon et al.¹⁴ will certainly challenge that implementation. Evaluating whether or not a government has adopted mechanisms that could help prevent and mitigate the influence of corporations and COI in public health policy is, therefore, only a starting point for further work in that space, both for research and advocacy.

Conclusions

Our methods for evaluating the progress made by governments in their implementation of mechanisms for preventing and mitigating the influence of corporations and COI in public health policy will help countries: systematize their efforts, benchmark their progress internationally, and give perspective on particular weaknesses, approaches, and investment gaps needed for change. We are planning to implement the proposed evaluation in Ireland as a first case-study, so that the methods discussed here will be further developed.

Ethical issues related to the study

Ethics approval has been received on 26 July 2020 from Trinity Business School, Trinity College Dublin in Ireland, for the conduct of the evaluation in Ireland.

Participation in the study will be voluntary. A decision not to consent will have no adverse consequences.

There would be minimal risks to participants, researchers, to the environment or any other persons. Some participants may know the researchers who will lead the evaluation and some participants will know each other, through their professional networks. However, we do not expect that this will serve to pressure participants to take part as they would be relatively senior in their organizations, well-versed in research processes, and highly-educated and experienced. The researchers leading the evaluation must have an extensive experience of working in the country they are studying and be aware of political and cultural sensitivities.

Participants should have the opportunity to review the transcript from the workshop to protect their anonymity and to take into account cultural and political sensitivities. Participants will be given a unique identifier code (e.g., IRL01) and only these codes will be included in field notes and transcripts, unless a participant agrees to share their details. For publication, only general identifiers (e.g. “policy maker”, “researcher”, etc.) will be used, unless a participant agrees to share their details. Data collected (audio recording), codes and consent forms will be in an identifiable form, and will be stored separate to transcripts and notes. If audio recordings are transcribed by a contracted translator, a confidentiality agreement will be signed with them.

Data availability