the Caribbean
María Eugenia Barbieri for the National Ministry of Health of Argentina;
Olga L. Sarmiento, Adriana Díaz del Castillo, and Ethel Segura Durán;
Evelyne Rodriguez; Amanda Sica, Franco González Mora, Winston Abascal and Ana Lorenzo for the Ministry of Public Health of Uruguay
This chapter documents governance issues in the design and implementation of some successful or promising population-wide interventions intended to prevent health risk factors in Latin America and the Caribbean (LAC).
Specifically, these case studies examine which stakeholders participated directly or indirectly in the decision-making process; what positions they held; which incentives they faced; which strategies they pursued; how exist-ing institutional arrangements affected the decision-makexist-ing process; what lessons can be drawn from these processes; and what the successes and set-backs were.
The case studies were selected from major population-wide, multisectoral programs in the region. The first four were considered to be some of the most representative and promising examples of policies and programs that promote healthy lifestyles and reduce risk factors for noncommunicable dis-eases (NCDs). Each case study was included because it examined a program or policy targeting a distinct risk factor. In addition, to ensure as wide as possible a representation, the case studies were drawn from different coun-tries. There was no case study commissioned on alcohol control. Although there are some good examples of alcohol-control policies in LAC, they are limited in their geographical focus or on the array of interventions or sectors involved.
The first four case studies deal with the following: Argentina’s policies to reduce the consumption of trans fats and sodium; Bogotá’s (Colombia) built environment that promotes physical activity; Mexico’s National Agreements on Food Health (Strategy against Overweight and Obesity); and Uruguay’s anti-tobacco policies. Because Argentina’s and Mexico’ policies are relatively new, c H A p t e r 5
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there is no available information on their effectiveness. They have been included here because they are some of the region’s most comprehensive policies in the fight against NCDs and because similar policies, or some elements of these poli-cies, have proven to be highly cost- effective elsewhere. Uruguay’s and Bogotá’s policies are older, and their effectiveness has been better documented. A fifth case—Argentina’s tobacco-control policies—was added to this analysis. Despite the fact that Argentina has not yet signed the Framework Convention on Tobacco Control (FCTC), the country has advanced in tobacco control, and its experience can provide important lessons for the region.
Argentina: Amending the Food code to regulate trans Fats and Agreements between the Government and the Food industry to reduce sodium in processed Foods
María Eugenia Barbieri for the National Ministry of Health of Argentina In an effort to reduce trans fats and sodium intake in diets, the Ministry of Health (MOH) initiated a dialogue with multiple actors—government agencies, food producers and distributors, universities and scientific societies, and the public. This dialogue led to agreements to amend the Food Code to regulate trans fats and meet targets for the reduction of sodium in processed foods. Of the two, the elimination of trans fats was the least problematic. It was technically feasible; experience outside Argentina, as well as research and development, had provided important models; and substitute products were available. In fact, 70 percent of the country’s food manufacturing companies were already restructuring their production processes when the dialogue started. Lowering salt intake was more difficult, however—sodium is a key ingredient in processed foods and baked goods, there is less aware-ness about its negative health effects, and fewer alternatives are available.
The governance of these policy-making processes was complex, given the participation of a wide array of stakeholders who faced different incentives.
Table 5.1 presents the key stakeholders that participated in both processes, their positions, the strategies they used, their interactions, and the lessons learned.
The MOH played a leading role in the effort to reduce trans fats and sodium in processed foods. Through its initiative, a National Commission to Eliminate Trans Fats and Reduce Salt was created. The Commission encompasses public and business organizations, scientific associations, and civil society groups, including the MOH; the Ministry of Agriculture, Livestock, and Fisheries (MoALF); the Ministry of Social Development; the Ministry of Science and Technology; the Ministry of Economy; the National Institute of Industrial Technology (INTI); the National Food Institute (INAL); the Argentine Federation of Baked Products Industry (FAIPA); the Coordinator of Food Products Industries (COPAL); the Argentine Fats and Oils Association (ASAGA); various business groups; some workers’ cooperatives; universities and scientific societies;
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table 5.1 Governance of multisectoral Activities to promote a Healthy Diet: Argentina’s Food code reform to regulate trans Fats in processed Foods and Agreements with the Food industry to reduce sodium
Key stakeholders and their positions Strategies Interaction among stakeholders Lessons learned
Ministry of Health (MOH): MOH Strengths:
• To protect the population against harmful effect of trans fats and excessive sodium intake.
National Food Institute (INAL); is part of the National Administration of Drugs, Food, and Medical Technology and depends on the Ministry of Health:
• Being part of the Ministry of Health, it held the same position.
National Institute of Industrial Technology (INTI): Although it shared the Ministry of Health’s position, it disagreed with it on some points:
• Before participating in negotiations, it called for an institutional agreement between INTI and the Ministry of Health to clarify its responsibilities in the process.
• Advocated for stricter sodium measures.
• Called for greater control of the use made by the companies of these measures.
• Called for greater discussion on how best to monitor the agreements.
• Wanted a comprehensive education campaign on the harmful effects of sodium and trans fats to be developed with the Ministry of Education.
• Called for greater efforts to contact small and medium enterprises and to disseminate information
• Advocated for continuity of the policies.
• Coordinated the process.
• Linked actions with other public agencies.
• Negotiated efforts with the private sector.
• Disseminated information to consumers.
INAL
• Contributed regulatory, technological, and monitoring knowledge.
• Presented the issue at provincial and municipal levels through the networks in which it participates.
• Technical staff participated in negotiations with the companies.
• Helped to design a manual about retrofitting small and medium enterprises’ production processes to eliminate trans fats.
INTI
• Its technical staff participated in negotiations with the companies.
• Provided training to the bakery sector on salt reduction.
• Presented and disseminated evidence on the viability of replacing trans fats in food.
• Helped to design a manual about retrofitting small and medium enterprises’ production processes to eliminate trans fats.
MoALF
• Contributed regulatory and technological knowledge.
• Disseminated information through various communication channels reporting to the Ministry that targeted to small and medium enterprises.
• Technical staff participated in negotiations with companies.
The Ministry of Health led the process. Its coordination with other government agencies was key, since the latter contributed with assistance and information about food technologies, regulations, and harmonization with MERCOSUR standards on food labeling, etc. These areas are beyond the Ministry of Health’s capacity.
In terms of sodium, technicians from INAL and INTI participated in discussions with the food companies and chambers of commerce on salt reduction measures and ways to launch them.
To support the small and medium size enterprises in the adaptation process, it was agreed that the government would support their efforts with information and assistance. In the case of trans fats, a guide on recommendations to substitute trans fats was developed with the participation of the government and the private sector.
In the case of trans fats, the cost of substitution technology has been decreasing over time. Thus, it was important for industry to agree with government on the time frame needed to reach the policy goals.
• Intersectoral dialogue and negotiation.
• Stewardship role of the Ministry of Health.
• Leadership and coordination with other public entities.
• Dialogue and negotiation with the private sector.
• The public-private joint effort for public health indicates the companies’ respect for consumers’ concerns.
Opportunities:
• An international climate fosters work on promoting healthy diets.
• Increasing consumer demand for healthy food.
• The creation of an intersectoral working group that led to modifying the Food Code.
Weaknesses:
• Limited resources.
• Small and medium enterprises missed out on the discussion about measures.
• A lack of laboratory
standardization to perform the tests to monitor and evaluate the measures.
• Voluntary agreements on lowering sodium content cannot be enforced.
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Key stakeholders and their positions Strategies Interaction among stakeholders Lessons learned
Ministry of Agriculture, Livestock and Fishing (MoALF)
• To promote the value added of healthy food in the market and create a regulatory framework.
COPAL (Coordinator of Food Product Industries):
• To negotiate goals and terms, avoiding the sudden implementation of measures which could be costly.
• Given international trend to work on these risk factors, knew they needed to work on these issues.
• To respond to growing consumer demand for healthy foods.
• Claimed that small and medium enterprises would have unfair advantages as they would have low probability of being inspected.
• Did not have the capacity to invest in the needed adaptations.
• To define uniform criteria to monitor compliance on the agreed goals.
• Their position with regards to reductions in sodium and trans fats were different because:
• Sodium is an inexpensive way to give flavor to many processed foods.
• With INTI, INAL, and ASAGA, supported industry through the design a manual for retrofitting small and medium enterprises’ production processes to eliminate trans fats.
COPAL
• Represented the business sector in negotiating the measures.
• Organized meetings with companies to agree on the terms and goals to be discussed with the Ministry of Health.
• Collected and delivered information on sodium content in food.
Threads
• Companies will probably want extensions to achieve the goals (particularly with regard to reducing sodium).
• Monitoring and evaluation:
• A limited capacity and availability of laboratories.
• Limited baseline information.
• Transnational companies that set their policies at the global level can hinder the agreed-upon agreements.
• A potential lack of continuity due to management changes over time.
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table 5.1 Governance of multisectoral Activities to promote a Healthy Diet: Argentina’s Food code reform to regulate trans Fats in processed Foods and Agreements with the Food industry to reduce sodium (continued)
Key stakeholders and their positions Strategies Interaction among stakeholders Lessons learned
• It also preserves foods and its substitution is difficult, relatively lower technical know-how than in the case of trans fats to find alternatives.
• Regarding trans fats, industry was already working to replace them given technical feasibility and the availability of foreign experience and R&D. However, the industry expressed concerned linked to the high cost of substitution of trans fats.
FAIPA (Argentine Federation of Baked Products Industry): They represented bakeries in the process of sodium reduction in artisanal breads.
• A commitment to health and good eating habits.
• Positive image among consumers, without requiring major investments or modifications of the production processes.
• Resistance of bakers to provide information on their products.
• Greater dissemination of the bakeries’
efforts.
• Greater resources to add more bakeries to the initiative.
• Continuity of the policies.
FAIPA
• Support the Ministry of Health in disseminating information about the initiative.
• Distribute and prepare materials to offer training materials to bakers.
• Providing seminars to train bakers.
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table 5.1 Governance of multisectoral Activities to promote a Healthy Diet: Argentina’s Food code reform to regulate trans Fats in processed Foods and Agreements with the Food industry to reduce sodium (continued)
Key stakeholders and their positions Strategies Interaction among stakeholders Lessons learned
ASAGA (Argentinean Association of Fats and Oils)
• To negotiate goals and terms, avoiding the sudden implementation of measures.
• To follow the international trend to work on these risk factors.
• Growing consumer demand for healthy foods.
• Cost of trans-fat substitution alternatives.
• Large enterprises complained that they would face unfair competition from small and medium companies because smaller businesses had low capacity for investment and low probability of being inspected.
• Define uniform criteria to monitor compliance on the agreed goals.
ASAGA
• Contribute technical know-how to replace trans fats.
• Represent the business sector in negotiating the measures.
• Organize meetings with companies to agree on the terms and goals to be discussed with the Ministry of Health.
• Design of a manual for retrofitting small and medium enterprises’ production processes to eliminate trans fats.
Note: R&D = research and development; MERCOSUR = Mercado Común del Sur (Common Market of the South).
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and consumer groups. Different working groups were set up within the commis-sion to advance trans-fat- and sodium-reducing policies; the groups discussed the concerns of all participating agencies and developed strategies to overcome these concerns.
Amending the Food Code to Regulate Trans Fats
The consumption of trans fats increases the risk of coronary heart disease and diabetes (Brunner and others 2007; Hu and others 1997, 2001). Coronary heart disease is a leading cause of death in Argentina and, according to the 2009 National Risk Factor Survey, 9.6 percent of the population reports having diabetes.
In 2007, the Pan American Health Organization (PAHO) created the “Trans Fat Free Americas” task force to evaluate the impact of trans fatty acids on nutri-tion and health and to find ways to gradually eliminate them. In 2008, the task force issued the Declaration of Rio de Janeiro, whereby it recommended replac-ing trans fats in processed foods and usreplac-ing a concentration no higher than 2 percent of total fat in oils and margarines and no higher than 5 percent in processed foods; requiring the food industry to place nutrition labels on its pro-cessed foods, stating the amount of trans fats they contain; developing educa-tional programs about different fats and the way to read labels; and forming national working groups with industry representatives, scientists, and public health authorities to address these issues.
Although Argentina’s authorities launched major efforts to reduce trans fats in 2008, the MOH had already introduced some measures in 2004, as recom-mended by the Program to Prevent Heart Attacks in Argentina (PROPIA) at the National University of La Plata (UNLP).
The Policy
Following discussions between the government and industry, an amendment to the country’s Food Code that would regulate the amount of trans fats in pro-cessed foods was prepared. The amendment was included in Article No. 155, Chapter III, which established that “The content of industrially-produced trans fatty acids in food should not exceed 2 percent of total fats in vegetable oils and margarines for direct consumption and 5 percent of total fats in other foods.
These limits do not apply to fats from ruminants, including milk fat.” The article was incorporated in December 2010 through Resolution No. 137 of the MOH’s Secretariat of Policies, Regulation, and Institutes and Resolution No. 941 of the then Secretariat of Agriculture, Livestock, and Fisheries—now the Ministry of Agriculture, Livestock, and Fisheries (MoALF)—and these resolution set a two-year timetable beginning December 2010 for modifying vegetable oils and mar-garines for direct consumption and up to four years for modifying other foods.
While the terms for replacing trans fats run their course, other efforts are cur-rently under way, such as disseminating information to small and medium indus-tries, which have greater difficulty in meeting the standard because they lack
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financial and technical resources to start the restructuring process; and launching campaigns to educate consumers about healthy diets. With respect to the first, a guide on recommendations and strategies for replacing trans fats was prepared for small and medium firms.1 Materials were also developed for consumers, with information on the damage to health from consuming trans fats and on how to read food labels. Based on Common Market of the South’s (MERCOSUR) reso-lution GMC No. 46, adopted in August 2006, the level of trans fats is required to be stated on the products’ labels.
Policy-Making Process
In 2008, the MOH took the lead by holding a national meeting to begin apply-ing the Rio recommendations. Participants included representatives from vari-ous government agencies, academia, and industry, who agreed to set up the following working commissions: an academic-scientific commission, coordi-nated by the UNLP; a regulatory-legislative commission, coordicoordi-nated by INAL;
and a communications-consumer commission, coordinated by the MoALF (then the Secretariat of Agriculture, Livestock, and Fisheries).
The regulatory-legislative commission was made up of several public agencies and representatives from the food industry. Among the public agencies were the Ministries of Health, MoALF, INAL, and INTI. Industry representatives included COPAL, the chambers of commerce, food and beverage companies, and ASAGA.
This last entity, which consists of technicians and companies involved in produc-ing and processproduc-ing fats, oils, and byproducts, was already workproduc-ing on ways to substitute trans fats for other products.
In 2008, the regulatory-legislative commission began to work on amending the Food Code. To that end, the group relied on international precedents. For example, in 2006, Denmark limited trans fats to 2 percent of the total content of fats in all marketed foods, and Canada recommended that trans fats should not exceed 2 percent of total fat content in vegetable oils and spreadable margarines or 5 percent in other foods.
Main Stakeholders, Their Positions, and Strategies
Throughout the process, MOH authorities sought to dialogue with all relevant actors, particularly the producers and distributors in the livestock and food sec-tors. The Ministry focused on issues such as producing healthier foods, using appropriate food labels, finding incentives—such as fiscal measures—to bring about sweeping changes, marketing techniques, creating interactions and partner-ships, enacting laws, setting regulations and enforcement mechanisms, and pro-viding the public with necessary information.2
Different participating organizations have adopted various roles. INAL, for example, which is part of the National Drugs, Food, and Medical Technology Administration and is a decentralized entity under MOH, played an important role in discussing measures to reduce trans fats; its knowledge about regulations, technology, food labeling, and analyses of trans-fat content made it particularly well suited for this position. At the MOH’s request, INAL coordinated the
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working group that addressed regulatory issues that led to the Food Code’s
working group that addressed regulatory issues that led to the Food Code’s