01.03.2011 «Partnerships only work if they are based on honest transparency.»
Interview. How important are partnerships between the public and private sectors – public-private partnerships, or PPPs for short – in the prevention and health promotion field both now and in the future? Spectra talked to professor of medicine Roger Darioli and consumer protection representative Mathieu Fleury about the opportunities and limits of public-private cooperation.
spectra: Where do you see the challenges and limits, and the risks and opportunities of PPPs?
R. Darioli: I’m in favour of PPPs provided clear conditions are observed, for example the rules of transparency and respect for ethical principles. Three ethical principles are crucial in my view. First, the benefits must be provided without harming the individual consumer or citizen. The second principle is social justice, which excludes individuals from profiting at the expense of the community. The third principle is to guarantee a certain degree of self-determination, in other words to ensure that everyone understands the societal challenges; this presupposes the required level of transparency.
M. Fleury: I agree with these perfectly formulated principles, even though we take a slightly more nuanced approach to PPPs. Our task in consumer protection is to take a critical look at companies. But since PPPs also extend to partially state-owned or private organisations that have particular skills, the state can trust them to perform certain tasks. PPPs are the result of a choice made by society – a political choice based on the current liberal trend that is aimed at reducing the tasks of the state to a minimum. As regards the limits of this exercise, in addition to the ethical principles already mentioned, I would add that the state must retain overall control. It must vouch for the democratic legitimacy of the project. In a public-sector context the state must retain sovereignty over projects and never be allowed to relinquish this responsibility.
Focusing on the subject of public health, what tasks can readily be integrated into PPPs and what tasks less so? And what tasks should not be integrated at all?
R. Darioli: In my view, partnership is especially appropriate for certain tasks in the area of prevention and health promotion. And, out of sheer necessity, curative medicine also offers scope for partnerships. Take the example of the basic provision of outpatient medicine. The disappearance of general practitioners and pharmacists has turned certain regions into regular healthcare deserts.
«The National Programme on Diet and Physical Activity (NPDPA) 2008–2012 selected an innovative approach entailing voluntary commitments, i.e. promises to implement corresponding campaigns.»
M. Fleury: I’d like to come back to how we define PPPs. Is the health insurance fund system a PPP, for example? With our idea of a public-sector health insurance fund, we are supporting the return of this system to state responsibility. As you can see, the field is fairly broad. However, there are various levels of partnership. Before the state introduces a PPP, it must always ask itself whether the partnership is necessary. The private sector must take part in the knowledge that while PPPs are without doubt a lucrative proposition, they also involve another, less comfortable, aspect – that of compulsion – which can neither be ruled out immediately nor viewed as wholly positive. The goal here is to find the right balance.
R. Darioli: I totally agree. This role of the state, which has a duty to protect the weakest from the strongest, is crucial. If the state lays out a clear strategy, intelligent partners can set up a partnership that is a win-win situation for everyone.
Turning to companies and their interest in getting involved in PPPs, what might their motivation be?
R. Darioli: Primarily it is the fear of self-regulation, even if this is not necessarily the best reason. One thing is clear: certain good corporate campaigns or large distributors aim primarily at preventing attacks in the form of class action lawsuits – the suits against the tobacco industry are a case in point. There may be some subsequent rethinking, an awareness that the company’s image could be improved with effective marketing. This aspect is important: the image of a company that supplies products that are sure to have a beneficial impact on health while also taking the need for fair working conditions and environmental compatibility into account.
What tasks in the medical, prevention and health promotion field must remain a matter for the state at any cost?
R. Darioli: I think the answer here is not so much fulfilment as control, which must rest with the state.
Can you give us some examples of successes?
M. Fleury: I can think of a trial which unfortunately ended unsuccessfully, but which nevertheless offers a promising approach: the «Choices» concept, which gave the food industry the opportunity to label products that most closely conform to a healthy diet. There was a genuine interest in reconciling the needs of marketing and consumers, i.e. helping people make the best choice. The project was perhaps not fully mature, but it will resurface. From now on, companies’ responsibility is at the centre of the debate, after that of the consumer. I believe that companies’ responsibility lies in the matter of choice, which they may have to change. Increasing numbers of labels do not help consumers. I’m trying to bring about a genuine sharing of responsibility. If we already require consumers to take responsibility for themselves, we can certainly help make their task a little easier.
Actionsanté is still a very cautious strategy that relies on companies’ goodwill. Is this approach too soft in your view?
R. Darioli: We have to be realistic. We have reached a turning point. Excessively strict rules would have a deterrent effect and would have no chance of succeeding in building up a partnership. The National Programme on Diet and Physical Activity (NPDPA) 2008–2012 selected an innovative approach entailing voluntary commitments, i.e. promises to implement corresponding campaigns. The modalities of this approach and its impact on health are being thoroughly evaluated. Certainly some companies undertake campaigns that are perfectly appropriate, clear, coherent and without risk. With regard to health-related campaigns, there is undoubtedly a not inconsiderable potential that deserves to be exploited and could trigger a snowball effect in other companies.
M. Fleury: actionsanté perhaps doesn’t go quite as far, but it’s faster. That’s one of the factors that convinced us. But we don’t want to abandon the idea of protecting the weakest. I believe that the state can act on the basis of a broad public consensus that children should not be the target group of marketing activities for foods that encourage an unbalanced diet. The exciting aspect of the project is that the ban is concerned neither with advertising nor unbalanced products, but rather with the promotion of an unhealthy diet to children who are not yet in a position to resist such products. The FRC (French Swiss Confederation of Consumers) thinks that it is possible to go even further and call for regulation by the state rather than wait for self-regulation.
Professor Darioli, what would you like to see happen in future? Where is there still a need for action?
R. Darioli: There’s still a lot to do in the area of nutrition. Salt is just a small part. Many inappropriate products are still being offered to consumers. And not just by the major distributors – take restaurants and canteens, for example, which are often extraordinarily inconsistent. In the field of nutrition, there are still many opportunities for facilitating the healthier choice that improves wellbeing and enjoyment of life. But a healthy lifestyle also requires physical activity, an important area where much still needs to be done. And in this connection we have to consider how work is organised and what effects this has on health. It’s encouraging to see that certain companies take a humanistic approach, that they’re not just interested in ensuring that their sophisticated machines work in order to maximise their profits, but that they also invest in the health of their employees. In fact, we all have to ask ourselves about our own responsibility – at the individual and family levels, but also at group, workplace and societal levels.
Let us return to actionsanté, which invites companies to act but does not pressure them. What do you think of that approach, Mr Fleury?
M. Fleury: We welcome any step in the right direction. But it’s true that we want more because we’re talking about major problems (particularly the overweight epidemic) that affect our children. We need to find effective measures in the most important areas. In our view this includes protecting children and teenagers from a constant stream of advertising while at the same time educating them about the importance of a balanced diet. There’s still a lot to do if we want to bring up the young generation to enjoy a simple, healthy diet and encourage them to avoid ready meals, which are making strong inroads. Given the nature of our work, which mainly involves comparing products with each other, it’s also clear that we are not satisfied with the information provided on packaging. It’s a veritable jungle. But we want aware consumers to be able to choose products on the basis of a real comparison. The industry’s marketing activities are all aimed at creating differences where none exist or at concealing differences that do exist. The consumer is the victim of this type of communication.
PPPs involve not only the state and companies, but also consumers.
M. Fleury: Absolutely. All our activities revolve around informed, responsible consumers who want to make their choice in full knowledge of the facts. But the responsibility is not theirs alone, and needs to be shared. For example, if consumers have lost their sense of the seasons by buying strawberries in winter, it is up to companies to put them back on track. If we want to respect the freedom of consumers and suppliers to buy and offer products out of season, these products should at least be presented in a more low-key fashion.
R. Darioli: We mustn’t forget that consumers have much more power than many of them think. It’s a power that can have a much faster impact than changes to the law. If they decide not to purchase a product that is of dubious origin, is produced under questionable working conditions or contains unsuitable ingredients, they are showing themselves to be responsible citizens who can persuade companies to improve their business policies.
The FOPH is thinking about a partnership on several levels to deal with the alcohol issue. This partnership will involve not only associations but also companies. What do you think about this?
M. Fleury: I’m not very familiar with this subject and it’s a tricky one. As with smoking, there’s a lot of hypocrisy and contradiction. Studies have demonstrated the ambiguity and ineffectiveness of the information campaigns. But we have to work with the industry, particularly when it comes to protecting the young
It’s difficult to ask firms to make less profit. I think that results will only be achieved in this area by threat.»
Companies have certainly realised that teenage alcoholism is bad for business. While a few successes may have been achieved here, it’s still difficult to ask firms to make less profit. I think that results will only be achieved in this area by threat. Where self-regulation fails, there will have to be regulation by the state. It’s in companies’ own interests to take the appropriate measures.
We’ve already mentioned the fact that smoking is a very tricky area, and no PPP is planned in this case.
M. Fleury: It’s true that if tobacco were to be introduced now, it would not stand a chance of being approved as a retail product. We therefore have to try to adjust to the historical reality. But how do you apply today’s rules to a product that was introduced in a different age? The real issue is that of passive smoking.
Do you, as the leading consumer protection representative in French-speaking Switzerland, have trust in companies that enter into commitments?
M. Fleury: I have a habit of merely lending my trust. In other words, I can withdraw it at any time. When a company enters into a commitment that is at odds with its core task, then I look for the reason. But even a commitment that looks rather unnatural at first sight can serve one aim particularly well: image enhancement. A company’s image has a highly specific value and bolsters business. Wherever there is a conflict between the natural aim of a company – i.e. to increase sales – and its actions, I remain vigilant and critical. When I see a true benefit for a company, then I believe that it’s acting sincerely.
Talking to spectra were:
Mathieu Fleury is General Secretary of the French Swiss Federation of Consumers (FRC) and thus the leading consumer protection representative in French-speaking Switzerland. In 2010, the FRC joined forces with consumer organisations in German- and Italian-speaking Switzerland to form the Alliance of Consumer Protection Organisations. One of their objectives is to achieve a clear ruling on the advertising of food products which are marketed as being healthy, but whose ingredients prove otherwise.
Professor Roger Darioli is Professor of Internal Medicine at the Faculty of Biology and Medicine at Lausanne University, Vice-president of the Swiss Society for Nutrition (SGE) and member of the Federal Nutrition Committee. He has completed additional training in nutritional science and lipidology. His clinical work and research interests focus mainly on the detection and prevention of cardiovascular disease.