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An accountability framework to promote healthy food environments

Published online by Cambridge University Press:  25 February 2014

Vivica I Kraak ,
Boyd Swinburn ,
Mark Lawrence  and
Paul Harrison
Vivica I Kraak*
Affiliation:
World Health Organization Collaborating Centre for Obesity Prevention, Deakin Population Health Strategic Research Centre, School of Health and Social Development, Faculty of Health, Deakin University, 221 Burwood Highway, Melbourne, Victoria 3125, Australia
Boyd Swinburn
Affiliation:
Population Nutrition and Global Health, University of Auckland, Auckland, New Zealand
Mark Lawrence
Affiliation:
Public Health Nutrition, School of Exercise and Nutrition Sciences, Faculty of Health, Deakin University, Burwood, Victoria, Australia
Paul Harrison
Affiliation:
School of Business, Faculty of Business and Law, Deakin University, Burwood, Victoria, Australia
*
*Corresponding author: Email vivica.kraak@gmail.com
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Abstract

Objective

To review the available literature on accountability frameworks to construct a framework that is relevant to voluntary partnerships between government and food industry stakeholders.

Design

Between November 2012 and May 2013, a desk review of ten databases was conducted to identify principles, conceptual frameworks, underlying theories, and strengths and limitations of existing accountability frameworks for institutional performance to construct a new framework relevant to promoting healthy food environments.

Setting

Food policy contexts within high-income countries to address obesity and diet-related non-communicable diseases.

Subjects

Eligible resources (n 26) were reviewed and the guiding principles of fifteen interdisciplinary frameworks were used to construct a new accountability framework.

Results

Strengths included shared principles across existing frameworks, such as trust, inclusivity, transparency and verification; government leadership and good governance; public deliberations; independent bodies recognizing compliance and performance achievements; remedial actions to improve accountability systems; and capacity to manage conflicts of interest and settle disputes. Limitations of the three-step frameworks and ‘mutual accountability’ approach were an explicit absence of an empowered authority to hold all stakeholders to account for their performance.

Conclusions

We propose a four-step accountability framework to guide government and food industry engagement to address unhealthy food environments as part of a broader government-led strategy to address obesity and diet-related non-communicable diseases. An independent body develops clear objectives, a governance process and performance standards for all stakeholders to address unhealthy food environments. The empowered body takes account (assessment), shares the account (communication), holds to account (enforcement) and responds to the account (improvements).

Keywords

Healthy food environmentsVoluntary partnershipsAccountability structuresCommitmentsPerformanceDisclosures
Type
HOT TOPIC – The WHO)s 2004 global strategy on diet, physical activity, and health: status and renewal of effort
Information
Public Health Nutrition , Volume 17 , Issue 11 , November 2014 , pp. 2467 - 2483
Copyright
Copyright © The Authors 2014 

Policy action to improve food environments exists at three levels: (i) development; (ii) implementation; and (iii) monitoring and evaluation. As rates of obesity and non-communicable diseases (NCD) increase worldwide(1), norm-setting institutions such as the WHO recommend that national governments have primary responsibility and authority to develop policies that create equitable, safe, healthy and sustainable food environments to prevent and control obesity and diet-related NCD(2–6).

Expert bodies recommend that governments engage all societal sectors to successfully reduce NCD(3). Diverse stakeholders can share responsibility to implement, monitor and evaluate policies without compromising the integrity of these efforts(2–7). However, national governments are increasingly sharing or relinquishing their responsibility for policy development with non-governmental stakeholders, especially unhealthy commodity industries that manufacture and market fast foods, sweetened beverages and alcohol, which is discouraged(Reference Swinburn, Sacks and Hall8–11).

A century ago, the US Supreme Court Justice, Louis Brandeis, emphasized the need for public information disclosure and law enforcement to hold the government and corporations accountable for their impacts on society(Reference Brandeis12). He is often remembered for the quote: ‘Publicity is justly commended as a remedy for social and industrial diseases. Sunlight is said to be the best of disinfectants; electric light the most efficient policeman.’

This observation is salient today to guide national governments’ engagement strategy with private-sector businesses and non-governmental organizations (NGO) to address unhealthy food environments and improve population health outcomes.

Governments are accountable to the people who elect them and are expected to protect the policy-making process from commercial interests by upholding robust standards to promote public interests over private interests, ensure transparency and manage conflicts of interest(Reference Swinburn, Sacks and Hall8–11). Some contend that there has been very limited progress to develop policies that support healthy food environments due to commercial interest-group pressures on government policy(Reference Swinburn, Sacks and Hall8–11).

The purpose of the present paper is to describe the current food policy-making context at the global level and in high-income countries before conducting an interdisciplinary evidence review of principles, frameworks and underlying theories about accountability for institutional performance. The results are used construct a new accountability framework to address unhealthy food environments. We discuss this framework using examples from high-income countries, which are relevant to government, food industry and NGO in low- and middle-income countries, to address obesity and diet-related NCD.

Background

The global context

The WHO's 2004 Global Strategy on Diet, Physical Activity and Health(2) emphasized different priorities for government, businesses and NGO. Governments are responsible for developing policy to support healthy food environments and ensure that all stakeholders follow recommended guidelines and laws. Businesses are responsible for adhering to laws and international standards, and NGO are responsible for influencing consumer behaviour and encouraging other stakeholders to support positive efforts.

Nearly a decade later, explicit language was included in the WHO's 2013–2020 global action plan to prevent and control NCD that encouraged collaborative partnerships among government agencies, civil society and the private sector to reduce NCD by 25 % by 2025(3). The resolution approved by 194 Member States encouraged national governments to ‘ensure appropriate institutional, legal, financial and service arrangements to prevent and control NCDs’(3). The WHO Director, Dr Margaret Chan, has criticized the food industry for opposing government regulation by blaming obesity on a lack of individual willpower instead of acknowledging the failure of governments to regulate ‘Big Business’(11).

Governments are faced with managing power imbalances that influence policy, institutionalized norms and governance processes. Accountability involves how and why decisions are made, who makes decisions, how power is used, whose views are important and who holds decision makers to account(Reference Rochlin, Zadek and Forstater13). Without strong and independent accountability structures, governments are unlikely to implement actions to manage the power imbalances that can influence the policy development and governance processes(Reference Muntaner, Ng and Chung14) to achieve the WHO's global target to reduce NCD morbidity and mortality(Reference Beaglehole, Bonita and Horton15).

In July 2013, the UN Economic and Social Council established a WHO-led Interagency Task Force to coordinate and implement all UN organizational activities supporting the WHO's 2003–2020 global NCD action plan(16). The Task Force represents a transnational governance structure to advise governments, NGO and the private sector on how to reduce obesity and diet-related NCD while safeguarding public health from potential conflicts of interest(16).

Food environments

Food environments are conceptualized and interpreted in different ways(Reference McKinnon, Reedy and Morrissette17–22). Empirical research suggests that food environments influence the dietary choices, preferences, quality and eating behaviours of individuals and populations(Reference McKinnon, Reedy and Morrissette17–22) at local, national and global levels. In the present paper, healthy food environments are defined as the collective economic, policy and sociocultural conditions and opportunities(Reference Swinburn, Egger and Raza21) across sectors (i.e. macro, meso and micro) and settings (i.e. home, schools, worksites, food retail outlets) that provide people with regular access to a healthy diet to achieve a healthy weight to prevent obesity and diet-related NCD (Fig. 1)(Reference Story, Kaphingst and Robinson-O'Brien20–22).

Fig. 1 A socio-ecological model illustrating stakeholders involved in promoting healthy food environments for populations (adapted from references 20–22)

Guidelines for a healthy diet encourage a variety of nutrient-dense foods and modest consumption of energy-dense foods to help people maintain a healthy weight(2, 4, 5, 7, 23, Reference Mozaffarian, Afshin and Benowitz24).

An unhealthy diet is linked to poorer health outcomes(Reference Pérez-Escamilla, Obbagy and Altman25) because it encourages people to overconsume energy, total fat, saturated fat, trans-fats, added sugars and salt(Reference Lin and Guthrie26, Reference Popkin, Duffey and Gordon-Larsen27).

Unhealthy diets and food environments drive three major NCD contributing to premature morbidity and mortality(1, 3). In 2010, seven of the top twenty deaths and disabilities worldwide were related to poor diet(Reference Lozano, Naghavi and Foreman28) and excessive salt consumption and inadequate fruit and vegetable intake contributed 10 % of the global burden of disease(Reference Lim, Vos and Flaxman29).

Government responsibility shifting to the private and non-governmental organization sectors

Since the 1970s, many Western democracies have embraced neoliberal governance models that support government de-regulation, privatization of public services and devolution of government responsibility to the private sector and NGO through public–private partnerships to address complex societal problems(Reference Guthman30–Reference Peck and Tickell32).

These trends have produced three outcomes. First, national governments have embraced private-interest language that has shifted the state's responsibility to address social problems from collective concerns to individual or family concerns requiring self-help solutions(Reference Guthman30–Reference Peck and Tickell32). Second, major public policy choices are framed as what governments can afford rather than what will benefit the public's interests(Reference Guthman30–Reference Peck and Tickell32). Third, private entities have used government legislative and legal institutions to secure corporate privileges over citizens’ rights(Reference Guthman30, Reference Wilst33, Reference Piety34).

Neoliberal approaches have fostered governance gaps in an era of industry self-regulation. Certain global food industry stakeholders have used their economic and political power to set policy agendas; engage in corporate lobbying and political campaign financing to legitimize commercial interests; and influence the regulatory decisions of government agencies(Reference Clapp and Fuchs35).

Some suggest that governments have conspired with the food industry to prevent meaningful action by using libertarian paternalism (i.e. ‘nudge approach’) and voluntary partnerships as the primary strategies to address unhealthy food environments(Reference Guthman30, Reference Clapp and Fuchs35–Reference Bonnell, McKee and Fletcher37) without adequate accountability structures to ensure that societal needs are met.

One example is the Public Health Responsibility Deal Food Network in England that has evoked criticism of voluntary industry engagement approaches because the government has not established consequences for non-participating companies or sectors(Reference Bonnell, McKee and Fletcher37). These concerns highlight the need for clear accountability structures to prevent the ‘corporate capture of public health’, where private-sector stakeholders can circumvent government regulation by encouraging voluntary cooperation through non-adversarial partnerships and oppose government regulation for economic reasons(Reference Mindell, Reynolds and Cohen36, Reference Bonnell, McKee and Fletcher37).

Responses to voluntary partnerships

Strategic alliances and voluntary partnerships are recommended by numerous authoritative bodies(2–7, 16, 22, Reference Mozaffarian, Afshin and Benowitz24) to address unhealthy food environments, yet these mechanisms were not intended as the central approach of a national obesity and NCD prevention strategy. Several types of voluntary partnerships have emerged to respond to nutrition-related challenges, ranging from undernutrition to obesity and diet-related NCD(Reference Kraak, Harrigan and Lawrence38). These partnerships remain controversial because evidence of their effectiveness to address specific food environment objectives, without undermining public health goals, is lacking(Reference Moodie, Stuckler and Monteiro10, Reference Kraak, Swinburn and Lawrence39–Reference Grynbaum42).

The food industry complex is comprised of many private-sector stakeholders who interact in different ways with government and other public and private entities to influence consumer demand and promote food and beverage product purchases and consumption(Reference Story, Kaphingst and Robinson-O'Brien20–22) (Fig. 1).

Food industry stakeholders have responded to obesity and NCD in several ways.

Some have formed alliances and partnerships at global(43), regional(44–47) and national(48–50) levels by committing to food product reformulation or developing new products with healthier nutrient profiles by reducing salt, energy and saturated fat, and eliminating trans-fats(43–45, 47–50); implementing community-based obesity prevention programmes(45, Reference Van Koperen, Jebb and Summerbell46); providing nutrition information, out-of-home energy (calorie) and front-of-package labelling to inform marketplace purchases(43, 49–51); and improving the quality of foods advertised and marketed to children and adolescents(43, 45, 52, 53) (Table 1). Industry alliances and companies also have disseminated reports outlining their accomplishments(48, 54) or contracted third-party auditors to assess, verify and report on their performance for more contested issues(55, Reference Vladu, Christensen and Pana56).

Table 1 Examples of food industry alliances and intersectoral partnerships to promote healthy food environments

CEO, chief executive officer; EU, European Union; NGO, non-governmental organization; PAHO, Pan American Health Organization.

Many public-interest NGO, professional societies and academics have observed that large food industry stakeholders have privileged access to policy makers that permits financial and political lobbying to support business interests over public health interests(57–Reference Wilst60). Corporate lobbying is one of many practices that has fuelled public-interest NGO distrust of food industry practices including voluntary partnerships to address obesity and NCD rates(9, Reference Moodie, Stuckler and Monteiro10, Reference Stuckler, McKee and Ebrahim61–Reference Lumley, Martin and Antonopoulos66). Despite the promise of collaborative approaches(Reference Kraak, Harrigan and Lawrence38) certain public health advocates have deemed them to be ineffective at tackling food environment policy issues(Reference Moodie, Stuckler and Monteiro10). Partnerships alone will not mitigate harmful commercial practices. Government legislation and regulatory oversight are also necessary to address unhealthy food environments(Reference Lumley, Martin and Antonopoulos66–Reference Sharma, Teret and Brownell69).

The background literature discussed shows that the issue of voluntary partnerships to address unhealthy food environments has primarily focused on establishing boundaries for stakeholders’ responsibility and measuring their effectiveness to achieve goals. There is limited empirical research on the accountability structures, processes and mechanisms required to build trust and ensure credibility for voluntary partnerships to promote healthy food environments. The current paper fills an important research and policy gap by seeking to integrate principles, conceptual frameworks and theories for institutional accountability to develop a new framework that national governments, food industry and NGO stakeholders can use to collectively promote healthy food environments to address obesity and diet-related NCD.

Design

The present review was guided by two research questions:

  1. 1. What types of accountability frameworks, principles and mechanisms are used to hold major stakeholders accountable for institutional performance to implement specific policies and actions to address unhealthy food environments?

  2. 2. How can these findings inform the development of an accountability framework to hold relevant stakeholders accountable for promoting and not undermining healthy food environments?

The accountability literature was initially explored to identify appropriate search terms. Due to the complexity and breadth of this literature, a systematic review was not used. Instead, an interdisciplinary literature review of ten databases (i.e. Academic Search Complete, Business Source Complete, CINAHL, Global Health, Health Business Elite, Health Policy Reference Center, Health Source, MEDLINE Complete, Political Science Complete and SocINDEX) was conducted over six months (November 2012 through May 2013) for English-language documents (from 1 January 2000 through 31 May 2013) to identify principles, conceptual frameworks and their underlying theories related to accountability for institutional performance. A combination of subject heading and text terms were used to search the databases including: accountability, responsibility, framework, government, industry, corporate, food companies, NGOs, civil society, media, partnerships, alliances, performance, commitment, compliance, legislation and regulation.

A total of 180 peer-reviewed journal articles, reports and books were retrieved, screened by title and abstract, and imported into an Endnote database. Full-text versions of potentially relevant sources were screened and read for inclusion. The reference lists of the included documents were searched and supplemented by the grey literature to identify conceptual frameworks, theories and principles related to accountability for institutional performance.

Results

The findings from twenty-six evidentiary sources based on fifteen existing interdisciplinary frameworks included in the current review are summarized in Table 2. These findings were used to develop a new accountability framework that government and other stakeholders can use to promote healthy food environments.

Table 2 Summary of evidence used from fifteen interdisciplinary frameworks to develop the healthy food environments accountability framework

OECD, Organization for Economic Cooperation and Development; IOM, Institute of Medicine; NCD, non-communicable disease; EU, European Union; NGO, non-governmental organization; CSR, corporate social responsibility.

Discussion

This section provides a synthesis of the frameworks reviewed. Although accountability has several different theoretical underpinnings and meanings across the disciplines of international relations(Reference Grant and Keohane70–Reference Steets72), trade(Reference Wolfe and Baddeley73) and development(Reference Joshi74, Reference O'Meally75); global governance for health and human rights(Reference Rochlin, Zadek and Forstater13, 76–Reference Bonita, Magnusson and Bovet81); business, finance and social accounting(Reference Deegan82–Reference Tilt89); social psychology and behavioural economics(Reference Irani, Sinclair and O'Malley90, Reference Dolan, Hallsworth and Halpern91); and public health policy and law(Reference Gostin92–94), there are common principles across these diverse disciplines.

Responsibility involves individuals, groups, government agencies and business firms acknowledging their commitments and obligations based on social, moral and/or legal standards(Reference Turoldo95). Accountability entails individuals or stakeholders answering to others empowered with authority to assess how well they have achieved specific tasks or goals and to enforce policies, standards or laws to improve desirable actions and outcomes. Accountability has traditionally entailed gathering information, monitoring and measuring financial or institutional performance against voluntary or mandatory standards, and using information to improve performance(Reference Rochlin, Zadek and Forstater13, Reference Grant and Keohane70–94).

Other accountability principles that are similar across existing frameworks are trust, inclusivity, transparency and verification; government leadership and good governance; public deliberations to respond to stakeholders’ interests and concerns; establishing or strengthening independent bodies (e.g. ombudsman or adjudicator); empowering regulatory agencies and using judicial systems to ensure fair and independent assessments; recognizing compliance and performance achievements with incentives (e.g. carrots) and addressing misconduct or non-performance with disincentives (e.g. sticks); and taking remedial actions to improve institutional performance and accountability systems(Reference Rochlin, Zadek and Forstater13, Reference Grant and Keohane70–94).

Accountability expectations for partnerships

The literature shows various accountability expectations for transnational alliances and partnerships depending on their purpose(Reference Steets72). Partnerships that raise awareness and advocate for important issues (e.g. Maternal Child Health Integrated Programme) emphasize compliance with rules and regulations, financial accountability and working towards the partnership's mission. Partnerships intended for self-regulation (e.g. Global Reporting Initiative) emphasize transparency and democratic participation. Partnerships for implementing a policy or programme (e.g. Global Alliance for Improved Nutrition) emphasize stakeholders’ performance for clearly defined objectives and performance outcomes. Partnerships used to generate information (e.g. World Action on Salt for Health) emphasize impartiality through professional independence, accuracy and quality(Reference Steets72).

Strengths and limitations of the frameworks reviewed

Of the fifteen accountability frameworks reviewed, ten were developed for the disciplines of international relations, trade and development(Reference Rochlin, Zadek and Forstater13, Reference Grant and Keohane70–Reference Steer and Wanthe77), human rights(79, 80) and global health(Reference Bonita, Magnusson and Bovet81).

One general framework was rooted in business, finance and social accounting(Reference Deegan82–Reference Tilt89). Two were rooted in social psychology(Reference Irani, Sinclair and O'Malley90) and behavioural economics(Reference Dolan, Hallsworth and Halpern91); and two were rooted in public health policy and law(Reference Gostin92–94). None of the frameworks were specific to promoting healthy food environments.

A strength of the public governance framework(Reference Bovens71) is the consideration of four concurrent factors (i.e. setting, stakeholders, conduct and obligations of interest) to achieve accountability outcomes. Many other frameworks included elements of a coherent accountability system but none integrated all of the cross-cutting accountability principles identified earlier.

Several limitations were apparent for the WHO and UN System's three-step frameworks to ‘monitor, review and act’ or ‘monitor, remedy and respond’(79–Reference Bonita, Magnusson and Bovet81). There is a need to differentiate between ‘remedy’ and ‘respond’ for an empowered authority to hold all stakeholders to account. Moreover, several frameworks lacked an explicit step to make system-wide changes to improve accountability structures based on continuous learning.

A four-step framework would include monitoring enforcement while also improving accountability structures.

Two shared governance frameworks(Reference Rochlin, Zadek and Forstater13, 76–Reference Ruger78) supported the concept of ‘mutual accountability’ whereby two or more partners agree to be held responsible for voluntary commitments they make to each other. However, mutual accountability arrangements lack enforcement structures, thereby requiring formal independent accountability mechanisms(Reference Muntaner, Ng and Chung14, Reference Bonita, Magnusson and Bovet81) to address complex public health problems such as obesity and diet-related NCD(Reference Moodie, Stuckler and Monteiro10, 11, Reference Muntaner, Ng and Chung14, 96).

The Institute of Medicine has identified four accountability steps to promote population health(93) that were central to informing our four-step framework and which include:

  1. 1. Establish a neutral and arms-length body with a clear charge to accomplish goals;

  2. 2. Ensure that the body has authority and capacity to undertake required activities;

  3. 3. Measure accomplishments against a clear charge given to the body; and

  4. 4. Improve accountability effectiveness by establishing a feedback loop to make system-wide improvements.

The Institute of Medicine identified several accountability challenges(93) such as: the limited ability to attribute the impact of promising interventions to a specific stakeholder group; a long time before an intervention's impact is observed; and the need to assess certain stakeholders’ actions that may concurrently support and undermine population health goals.

Accountability framework to promote healthy food environments

The accountability framework that we developed is based on government appointing an empowered and independent body with a well-defined charge to develop clear objectives, a governance process, performance standards and indicators for all stakeholders to address unhealthy food environments, and to report back on progress. The four-step framework involves taking account (assessment), sharing the account (communication), holding to account (enforcement) and responding to the account (improvements; Fig. 2).

Fig. 2 Accountability framework to promote healthy food environments

Although it is a non-linear process, we describe it in a stepwise manner to simplify one's understanding of the accountability dimensions. The governance process should be transparent, credible, verifiable, trustworthy, responsive, fair and timely; and have institutionalized mechanisms to identify and manage conflicts of interest and settle disputes.

Taking the account

This step involves an independent body collecting, reviewing, verifying, monitoring and evaluating meaningful data to establish benchmarks and to analyse each stakeholder's compliance with implementing policies and practices that impact food environments and diet-related population health. Clear reporting expectations and time frames are needed to achieve specific performance goals.

Evidence reviews

UN System bodies, governments and private foundations have appointed expert committees and independent commissions to review public-domain evidence from peer-reviewed and grey literature and trusted advisors(Reference Haynes, Derrick and Redman97), NGO and self-reported industry evidence(55, Reference Vladu, Christensen and Pana56, 98, 99), or investment banking firms and contracted auditors who use specific indices that compare and rank company performance for corporate social responsibility indicators within certain sectors(100, 101).

Monitoring and evaluating policy interventions

The WHO global monitoring framework and action plan to reduce NCD by 25 % by 2025 offers nine voluntary global targets and twenty-five indicators(3, 16) that will require tailoring to national contexts. INFORMAS(Reference Swinburn, Sacks and Vandevijvere102) is a network of researchers from nine universities across fourteen countries who monitor food environment policy interventions to prevent obesity and diet-related NCD. Government progress can be assessed using the Healthy Food Environment Policy Index(Reference Swinburn, Vandevijvere and Kraak103) and food industry progress can be assessed across seven food environment domains (i.e. composition, labelling, promotion, provision, retail, pricing, and trade and investment) using a prioritized, step-based approach(Reference Sacks, Swinburn and Kraak104).

The Access to Nutrition Index (ATNI) is another independent monitoring effort that rates twenty-five global food and beverage manufacturers on nutrition-related commitments, disclosure practices and performance to address undernutrition and obesity(105). The ATNI used seven indicators (i.e. corporate governance, product portfolio, accessibility of products, marketing practices, support for healthy lifestyles, food labelling and stakeholder engagement) to rate companies for promising or best practice achievements. The 2013 ATNI evaluation found most companies lacked transparency by not publicly sharing their nutrition-related practices and did not adhere to many public commitments(105).

Evaluations of the European Union's (EU) Platform for Action on Diet, Physical Activity and Health revealed that defining clear measurable objectives is essential for policy makers to determine the value of the EU Platform's partnerships(45, 106). Evaluations of the Pan American Health Organization/WHO Trans Fat Free America initiative found that national governments must coordinate all efforts – including tracking industry reformulation, ensuring mandatory food labelling requirements are consistent across countries, and monitoring changes in the food supply and the dietary intake of populations – to effectively eliminate trans-fats from the food supply in the Latin American and the Caribbean region(Reference Monge-Rojas, Colón-Ramos and Jacoby107, Reference Colón-Ramos, Monge-Rojas and Campos108).

In the USA, private foundations are funding independent evaluations to verify and review progress for private-sector pledges to improve food environments. Examples include the sixteen food manufacturers’ 2010 pledge to remove 1·5 trillion calories from the US food supply by 2015 through the Health Weight Commitment Foundation (Table 1)(48, Reference Slining, Wen and Popkin109) and the Partnership for a Healthier America(110).

Sharing the account

This step involves the empowered body communicating results to all stakeholders through a deliberative and participatory engagement process. This step is important to encourage transparency and understanding among stakeholders about the development of the performance standards and accountability expectations; to foster dialogue among stakeholders who hold divergent views and positions on food environment issues; to facilitate shared learning among diverse stakeholders to foster understanding of positions and constraints; to develop timelines for action; and to inform accountability actions at subsequent steps.

Stakeholder engagement can provide insights into accountability needs and challenges related to balancing divergent perspectives. On example is the UK ‘Race to the Top’ project that had convened food retailers and civil society groups to establish sustainability benchmarks(Reference Fox and Vorley111). The evaluation showed that public-interest NGO viewed the engagement process as too conciliatory whereas the food retailers perceived that there was insufficient consensus building. Participating NGO also criticized the overreliance on food retailers’ self-reported data and the lack of consequences for non-participating companies. On the other hand, food retailers were concerned that their participation in the process would be used to develop a new government regulatory framework to raise expectations about their performance(Reference Fox and Vorley111).

Holding to account

Holding to account is the most difficult step in the framework because it involves an empowered group appraising and either recognizing successful performers or enforcing policies, regulations and laws for non-participants or under-performers through institutional, financial, regulatory, legal or reputational mechanisms(Reference Grant and Keohane70). Accountability challenges exist at the international level because treaties, conventions and resolutions have limited sanctioning powers to hold national governments accountable for healthy food environments. The 2010 resolution to reduce unhealthy marketing to children recommended ten actions(112) but the WHO lacks legal authority, oversight or enforcement capacity to compel governments to reduce unhealthy food marketing to children.

National governments can leverage incentives (e.g. tax breaks, investment decisions or praising) and disincentives (e.g. fines, divestment, penalties, litigation, naming or shaming)(Reference Grant and Keohane70) to hold stakeholders accountable for policies and practices that impact food environments. Some of the most effective voluntary agreements include disincentives and reputational costs for non-participation and sanctions for non-compliance(Reference Grant and Keohane70, Reference Bryden, Petticrew and Mays113).

Adjudication is another option where a national government can appoint an ombudsman to mediate and manage disputes to avoid litigation and address complex dilemmas arising from power asymmetries among food environment stakeholders(Reference Burch, Lawrence and Hattersley114). In 2013, an independent UK Groceries Code Adjudicator was appointed to ensure that large food retailers will adhere to the Groceries Supply Code of Practice and treat suppliers fairly within legal guidelines(115).

Holding to account also involves public-interest NGO pursuing ‘social accountability goals’(Reference Joshi74, Reference O'Meally75) by exposing unacceptable practices such as government corruption and food industry lobbying that undermine public health goals(116, 117). NGO can utilize disclosure laws that compel governments to release information(118); work with investigative journalists to expose practices that adversely impact food environments and population health(Reference Schlosser119–Reference Taubes and Couzens121); use consumer and company boycotts(Reference Hines and Jernigan122–Reference Chapman124); use parents’ juries(125); praise companies that meet performance expectations and name or shame non-participating or under-performing businesses(Reference Dorfman, Wilbur and Lingas126–128); encourage corporations to endorse investors’ statements that recognize health, wellness and nutrition as drivers of future economic-sector growth(99, Reference Dorfman, Wilbur and Lingas126, Reference Kropp129); and spearhead shareholder advocacy to change corporate practices(Reference Dorfman, Wilbur and Lingas126, 130) and persist even when resolutions are rejected by company boards(Reference Baertlein131).

Responding to the account

Responding to the account involves stakeholders taking remedial actions to improve their performance and strengthen systemic accountability structures. This step involves monitoring the fidelity of government policy implementation (which differs from monitoring stakeholders’ compliance with existing policies), as well as government's enforcement of policies, regulations and laws. It also involves assessing how effectively the empowered authority applies incentives and disincentives to promote healthy food environments.

Step 4 involves building stronger internal and external approaches to track a company's performance on commitments and targets. Finally, this step addresses ‘pseudo accountability’, by challenging weak regulations that give an appearance of enforcing high standards but do not lead to meaningful changes(Reference Kassirer132).

Implications

The proposed accountability framework has several implications. First, it can be used to inform, guide and model private-sector practices to optimize good performance and minimize undesirable or unintended corporate practices. Second, holding to account and responding to the account offer recommendations that have been weak in existing frameworks. Third, the framework encourages stakeholders to explicitly examine power relationships and accountability expectations at all four steps. Fourth, several formal and informal mechanisms are provided for stakeholders to hold each other to account. Finally, the proposed framework requires empirical testing for relevant issues, and especially to evaluate whether the accountability structures of voluntary partnerships can be strengthened to improve credibility, quality of engagement and produce a positive impact on healthy food environments.

Conclusions

National governments’ reliance on food industry partnerships to develop and implement policies to address unhealthy food environments requires explicit, transparent and independent accountability structures. The proposed accountability framework involves an empowered body developing clear objectives, a governance process and performance standards for all stakeholders to promote healthy food environments. The body takes account (assessment), shares the account (communication), holds to account (enforcement) and responds to the account (improvements). The governance process must be transparent, credible, verifiable, trustworthy, responsive, fair and timely, and manage conflicts of interest and settle disputes. The proposed framework requires empirical testing to evaluate whether the accountability structures can be strengthened to improve partnership credibility, engagement and impact on healthy food environments within a broader government-led strategy to address obesity and diet-related NCD.

Acknowledgements

Sources of funding: This paper was supported by the World Health Collaborating Centre for Obesity Prevention and the Population Health Strategic Research Centre at Deakin University in Melbourne, Victoria, Australia. V.I.K. received PhD research support from Deakin University's World Health Collaborating Centre for Obesity Prevention and the Population Health Strategic Research Centre to complete this paper, and otherwise has no financial disclosures. B.S., M.L. and P.H. have no financial disclosures. Conflicts of interest: V.I.K., B.S., M.L. and P.H. have no conflict of interest related to the content in this paper. Ethics approval: This study was a desk review of the literature and did not involve human subjects; therefore ethics approval was not required. Authors’ contributions: V.I.K. developed the initial concept, conducted the literature review, wrote the first draft, coordinated feedback for subsequent revisions and led the submission process. B.S., M.L. and P.H. further developed the concepts and provided feedback on drafts of the paper. All authors read and approved the final manuscript. Acknowledgements: The authors are grateful to Juan Quirarte for designing Figs 1 and 2.

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Figure 0

Fig. 1 A socio-ecological model illustrating stakeholders involved in promoting healthy food environments for populations (adapted from references 20–22)

Figure 1

Table 1 Examples of food industry alliances and intersectoral partnerships to promote healthy food environments

Figure 2

Table 2 Summary of evidence used from fifteen interdisciplinary frameworks to develop the healthy food environments accountability framework

Figure 3

Fig. 2 Accountability framework to promote healthy food environments