Abstract

This study analyzed potential conflicts of interest regarding the commercial private sector and health promotion policies, particularly their interface with the food and nutrition field in Brazil. The paper addresses the influence of international ideas in this process. The study analyzed the two separate publications of the Brazilian National Health Promotion Policy – of 2006, and of 2014 – and the international agreements that supported them. The method used was analysis of documents, with a categorization into the following dimensions and categories: In the dimension of the Ideas of health promotion, the focus items were the principles and the strategies proposed; In the dimension of conflicts of interest, these aspects were identified: the approach in the documents, relationships with the commercial private sector, and proposals referred to as ‘public-private partnerships’. It was concluded that these policies still adopt a fragile approach in terms of conflict of interest. The debate is de-politicized when the asymmetries of power between the sectors involved in the public-private relationships are not made explicit, or when the practices of the commercial private sector that harm objectives, principles and values of health promotion policies are left out of account.

Conflict of interest; Public health policies; Nutrition programs and policies; Public sector; Public-private partnerships

Introduction

Analysis of policies of health and nutrition, both in the international scenario¹1. McNutt K. Conflict of interest. J Am Diet Assoc 1999; (1):29-30.

2. Warner TD, Gluck JP. What do we really know about conflicts of interest in biomedical research? Psychopharmacology 2003; 171(1):36-46.

3. Rothman DJ, McDonald WJ, Berkowitz CD, Chimonas SC, De Angelis CD, Hale RW, Nissen SE, Osborn JE, Scully Junior JH, Thomson GE, Wofsy D. Professional medical associations and their relationships with industry: a proposal for controlling conflict of interest. J Am Med Assoc 2009; 301(13):1367-1372.

4. Freedhoff Y, Hébert PC. Partnerships between health organizations and the food industry risk derailing public health nutrition. CMAJ 2011; 183(3):291-292.

5. Stuckler D, MC Kee M, Ebrahim S, Basu S. Manufacturing epidemics: the role of global producers in increased consumption of unhealthy commoditties including processed, alcohol and tobacco. Plos Med 2012; 9(6):e1001235.

6. Moodie R, Stuckler D, Monteiro CA, Sheron N, Neal B, Thamarangsi T, Lincoln T, Casswell S. Profits and pandemics: prevention of harmful effects of tobacco, alcohol, and ultra-processed food and drink industries. Lancet 2013; 381(9867):670-679.^-77. Ottersen OP, Dasgupta J, Blouin C, Buss P, Chongsuvivatwong V, Frenk J, Fukuda-Parr S, Gawanas BP, Giacaman, R, Gyapong J, Leaning J, Marmot M, McNeill D, Mongella G, Moyo N, Møgedal S, Ntsaluba A, Ooms G, Bjertness E, Lie AN, Moon S, Roalkvam S, Sandberg KI, Scheel IB. The political origins of health inequity: prospects for change. Lancet 2014; 383(9917):630-667., and in the Brazilian context⁸8. Pinheiro ARO, Carvalho DBP. Estado e mercado: adversários ou aliados no processo de implementação da Política Nacional de Alimentação e Nutrição? Elementos para um debate sobre medidas de regulamentação. Saúde Soc 2008; 17(2):170-183.

9. Gomes FS, Castro IRR, Monteiro CA. Publicidade de alimentos no Brasil: avanços e desafios. Cienc. Cult. [periódico na Internet]. 2010 Out [acessado 2014 set 15]; 62(4):48-51. Disponível em: http://cienciaecultura.bvs.br/scielo.php?script=sci_arttext&pid=S0009-67252010000400015
http://cienciaecultura.bvs.br/scielo.php...

10. Preza DLC, Augusto LGS. Vulnerabilidades de trabalhadores rurais frente ao uso de agrotóxicos na produção de hortaliças em região do Nordeste do Brasil. Rev Bras Saúde ocup [periódico na Internet]. 2012 Jan-Jul [acessado 2015 mar 21]; 37(125):89-98. Disponível em: http://dx.doi.org/10.1590/S0303-76572012000100012
http://dx.doi.org/10.1590/S0303-76572012...

11. Burlandy L. Gomes FS, Carvalho CM, Dias PC, Henriques P. Intersetorialidade e potenciais conflitos de interesses entre governos e setor privado comercial no âmbito das ações de alimentação e nutrição para o enfrentamento de doenças crônicas não transmissíveis. Vigil Sanit Debate: Sociedade, Ciência & Tecnologia 2014; (2):124-129.^-1212. Henriques P, Dias PC, Burlandy L. A regulamentação da propaganda de alimentos no Brasil: convergências e conflitos de interesses. Cad Saúde Pública 2014: 30(6):1219-1228., indicates how potential conflicts of interest can affect the design and the course of implementation of governmental actions.

These actions mobilize a significant volume of public funds and involve large-scale economic interests. Thus, conflicts arising in relation to the appropriation of these funds can cut across the whole political process. The very terms of policies are disputed: the concepts about the problems; the justifications for instituting certain measures and not others; and other issues⁸8. Pinheiro ARO, Carvalho DBP. Estado e mercado: adversários ou aliados no processo de implementação da Política Nacional de Alimentação e Nutrição? Elementos para um debate sobre medidas de regulamentação. Saúde Soc 2008; 17(2):170-183.

9. Gomes FS, Castro IRR, Monteiro CA. Publicidade de alimentos no Brasil: avanços e desafios. Cienc. Cult. [periódico na Internet]. 2010 Out [acessado 2014 set 15]; 62(4):48-51. Disponível em: http://cienciaecultura.bvs.br/scielo.php?script=sci_arttext&pid=S0009-67252010000400015
http://cienciaecultura.bvs.br/scielo.php...

10. Preza DLC, Augusto LGS. Vulnerabilidades de trabalhadores rurais frente ao uso de agrotóxicos na produção de hortaliças em região do Nordeste do Brasil. Rev Bras Saúde ocup [periódico na Internet]. 2012 Jan-Jul [acessado 2015 mar 21]; 37(125):89-98. Disponível em: http://dx.doi.org/10.1590/S0303-76572012000100012
http://dx.doi.org/10.1590/S0303-76572012...

11. Burlandy L. Gomes FS, Carvalho CM, Dias PC, Henriques P. Intersetorialidade e potenciais conflitos de interesses entre governos e setor privado comercial no âmbito das ações de alimentação e nutrição para o enfrentamento de doenças crônicas não transmissíveis. Vigil Sanit Debate: Sociedade, Ciência & Tecnologia 2014; (2):124-129.^-1212. Henriques P, Dias PC, Burlandy L. A regulamentação da propaganda de alimentos no Brasil: convergências e conflitos de interesses. Cad Saúde Pública 2014: 30(6):1219-1228..

The conflicts of interest that involve the interests of the commercial private sector deserve attention, whether for the growing influence of transnational corporations in the political process, or because practices (such as, for example, market strategies for unrestricted stimulus to buying and consumption) and products (e.g. ultra-processed food, and pesticides) of this sector have been associated with increases in chronic non-communicable diseases (CNCD) and their risk factors⁵5. Stuckler D, MC Kee M, Ebrahim S, Basu S. Manufacturing epidemics: the role of global producers in increased consumption of unhealthy commoditties including processed, alcohol and tobacco. Plos Med 2012; 9(6):e1001235.

6. Moodie R, Stuckler D, Monteiro CA, Sheron N, Neal B, Thamarangsi T, Lincoln T, Casswell S. Profits and pandemics: prevention of harmful effects of tobacco, alcohol, and ultra-processed food and drink industries. Lancet 2013; 381(9867):670-679.^-77. Ottersen OP, Dasgupta J, Blouin C, Buss P, Chongsuvivatwong V, Frenk J, Fukuda-Parr S, Gawanas BP, Giacaman, R, Gyapong J, Leaning J, Marmot M, McNeill D, Mongella G, Moyo N, Møgedal S, Ntsaluba A, Ooms G, Bjertness E, Lie AN, Moon S, Roalkvam S, Sandberg KI, Scheel IB. The political origins of health inequity: prospects for change. Lancet 2014; 383(9917):630-667.^,1010. Preza DLC, Augusto LGS. Vulnerabilidades de trabalhadores rurais frente ao uso de agrotóxicos na produção de hortaliças em região do Nordeste do Brasil. Rev Bras Saúde ocup [periódico na Internet]. 2012 Jan-Jul [acessado 2015 mar 21]; 37(125):89-98. Disponível em: http://dx.doi.org/10.1590/S0303-76572012000100012
http://dx.doi.org/10.1590/S0303-76572012... ^,1313. Carneiro FF, Augusto LGS, Rigotto RM, Friedrich K, Búrigo AC. Dossiê ABRASCO: um alerta sobre os impactos dos agrotóxicos na saúde. Rio de Janeiro, São Paulo: EPSJV, Expressão Popular; 2015..

Among the group of health policies that can be affected, health promotion strategies take on particular importance because they can signal existence of pacts involving the commercial private sector as a possible solution for health problems. Analysis of potential conflicts of interest can expand understanding of the political disputes in this field and indicate implications for achieving health objectives.

Internationally, the inventory of ideas on health promotion has been fostered by the World Health Organization (WHO) since the 1970s, and disseminated by a group of events and documents, such as the Global Conferences and the Health Promotion Policy Letters, which have influenced governmental action in various countries¹⁴14. Carvalho SR. As contradições da promoção à saúde em relação à produção de sujeitos e a mudança social. Cien Saude Colet 2004; 9(3):669-678.^,1515. Silva KL, Sena RR, Akerman M, Belga SMM, Rodrigues AT. Intersetorialidade, determinantes socioambientais e promoção da saúde. Cien Saude Colet 2014; 19(1):4361-4370.. In Brazil, the two instances of the National Health Promotion Policy (NHPP)¹⁶16. Brasil. Ministério da Saúde (MS). Política Nacional de Promoção da Saúde. Brasília: MS; 2006.^,1717. Brasil. Ministério da Saúde (MS). Portaria nº 2.446, de 11 de Novembro de 2014. Redefine a Política Nacional de Promoção da Saúde. Diário Oficial da União 2014; 12 nov. enter into a dialog with this inventory of ideas.

Although the conception of health promotion is not uniform¹⁴14. Carvalho SR. As contradições da promoção à saúde em relação à produção de sujeitos e a mudança social. Cien Saude Colet 2004; 9(3):669-678.^,1818. Ferreira Neto JL, Kind L, Resende MCC, Colen NS. Processos da construção da Política Nacional de Promoção da Saúde. Cad Saude Publica 2013; 29(10):1997-2007.^,1919. Silva PFA, Baptista TWF. Os sentidos e disputas na construção da Política Nacional de Promoção da Saúde. Physis 2014; 24(2):441-465., the approach to health in all the policies indicates that the relationships between health, wellbeing and equality, and economic development need to be taken into account in the public agenda through new political pacts between government and ‘non-governmental’ sectors²⁰20. Organização Mundial da Saúde (OMS). Declaração de Adelaide sobre a Saúde em Todas as Políticas: no caminho de uma governança compartilhada, em prol da saúde e do bem-estar. 2010. [acessado 2015 nov 2]. Disponível em: http://www.who.int/social_determinants/publications/isa/portuguese_adelaide_statement_for_web.pdf
http://www.who.int/social_determinants/p... ^,2121. World Health Organization (WHO). The Helsinki Statement on Health in All Policies. Helsinki, 2013. [acessado 2015 nov 2]. Disponível em: http://www.healthpromotion2013.org/images/8GCHP_Helsinki_Statement.pdf
http://www.healthpromotion2013.org/image... .

However, the political process underlying the construction of these policies and pacts is not exempt from conflicts of interest of various types, especially when dealing with articulation of health promotion actions with economic growth/development. In this context, the interests of the governmental sectors, civil society and the commercial private sector (which are, per se, heterogeneous and marked by internal conflicts) are in constant dispute, even though they may converge in some specific situations.

In view of the importance of this debate, the study analyzed the potential conflicts of interest that involve the commercial private sector in the ambit of national health promotion policies and international health promotion agreements, highlighting a focus on the subjects of diet and nutrition. The study sought to identify points of focus, principles, values, strategies and the approach to conflict of interest in these policies.

Theoretical frame of reference, and methods

The concept of conflict of interest (COI) has been widely problematized in the international literature, although the number of studies that deal with this subject in relation to diet and nutrition is not large²²22. Gomes FS. Conflito de interesse em alimentação e nutrição. Cad Saude Publica 2015; 31(10):2039-2046.. In Brazil, Law 12813 of May 16, 2013²³23. Brasil. Lei nº 12.183, de 16 de maio de 2013. Dispõe sobre o conflito de interesses no exercício de cargo ou emprego do Poder Executivo federal e impedimentos posteriores ao exercício do cargo ou emprego e dá outras providências. Diário Oficial da União 2013; 17 maio., and Interministerial Order 333 of September 19, 2013²⁴24. Brasil. Portaria Interministerial nº 333, de 19 de setembro de 2013. Disciplina a consulta sobre a existência de conflito de interesses e o pedido de autorização para o exercício de atividade privada por servidor ou empregado público do Poder Executivo Federal. Diário Oficial da União 2013; 20 set., characterize conflict of interest as ... the situation generated by a confrontation between public and private interests, such as could harm the collective interest or improperly influence performance of the public function.

The sphere of public action goes beyond the frontiers of the various components of apparatus of the state and of government policies, and there are multiple policies networks and interests that connect the commercial private sector with organizations of society and governments. Thus the debate on conflict of interest opens a wide range of questions on definition of the public and private interest; on the (im)possibilities of these sectors being treated in such a distinct and dual way (given the privatization of the public and the different types of interests that cut across governments); the distinctions of the private sector (profit or non-profit; philanthropic; commercial) and, consequently, what precisely is to be called a conflict of interest¹¹11. Burlandy L. Gomes FS, Carvalho CM, Dias PC, Henriques P. Intersetorialidade e potenciais conflitos de interesses entre governos e setor privado comercial no âmbito das ações de alimentação e nutrição para o enfrentamento de doenças crônicas não transmissíveis. Vigil Sanit Debate: Sociedade, Ciência & Tecnologia 2014; (2):124-129.^,2222. Gomes FS. Conflito de interesse em alimentação e nutrição. Cad Saude Publica 2015; 31(10):2039-2046.. To avoid analytical reductionisms arising from these categorizations, policy collectives suggest that analysis of conflict of interest should consider whether the products, practices and institutional policies of the sectors injure interests, objectives and principles that orient the public actions and policies constructed in each geopolitical territorial context²²22. Gomes FS. Conflito de interesse em alimentação e nutrição. Cad Saude Publica 2015; 31(10):2039-2046.^,2525. Castro IRR. Relação público-privado, conflito de interesses e a agenda regulatória para a consolidação da democracia. Ensaios e Diálgos em Saúde Coletiva 2015; 1:74-80..

Based on these frames of reference, the study used as it basic structure the method of analysis of documents²⁶26. Cellard A. Análise documental. In: Poupart J, Deslauriers JP, Groulx LH, Laperrière A, Mayer R, Pires A. A pesquisa qualitativa. Enfoques epistemológicos e metodológicos. Petrópolis: Vozes; 2008. p. 295-316., and the conception of documents as discursive practices (constructed in a given situation, time and space) and strategies of power that indicate possible agreements in a given context of disputes of interests and conceptions. The discourse formalized in them is a social practice, because it not only presents ideas or representations about reality, but institutes processes and categorizes reality itself, through the production of meanings²⁷27. Spink MJ, Menegon VM. Práticas discursivas como estratégia de governamentalidade: a linguagem dos riscos em documentos de domínio público. In: Iniguez L, organizador. Manual de análise do discurso em ciências sociais. Petrópolis: Vozes; 2005. p. 312.^,2828. Freeman R, Maybin JO. Documents, practices and policy. Evid Policy 2011; 7(2):155-170.. Considering the indissociability between discourse and practice, Griggs and Howarth²⁹29. Griggs S, Howarth D. Discourse and practice: using the power of well-being. Evid Policy 2011; 7(2):213-226. propose that studies in this field should problematize the regimes of practices in a given context, the different forms in which a question is approached and how these regimes make possible the inclusion and exclusion of given political subjects and questions. Further, they highlight that the analysis should consider the conditions of production and the logics of the discourse, including the identification of narratives that mask and ‘naturalize’ the relationships of power, by treating questions that are socially constructed as if they were ‘natural’ or ‘given’²⁹29. Griggs S, Howarth D. Discourse and practice: using the power of well-being. Evid Policy 2011; 7(2):213-226.. Based on these conceptions as reference, the analysis of documents was organized based on the following dimensions and categories: (1) in the dimension of the inventory of health promotion ideas, the following points of focus in health promotion were problematized: principles, values, directives/guidelines and strategies proposed in the policies; (2) in the dimension of conflict of interest, the approach given to the subject was considered through analysis of the relationships with the commercial private sector and proposals referred to as ‘public-private partnerships’ (PPPs).

International documents were analyzed that historically disseminated the idea-inventory of health promotion since the 1970s and Brazilian policies that formalized proposals for the Brazilian scenario: The Lalonde Report³⁰30. Lalonde M. A new perspective on the health of Canadians.1974. [acessado 2015 nov 2]. Disponível em: http://www.hcsc.gc.ca/hppb/phdd/pdf/perspective.pdf
http://www.hcsc.gc.ca/hppb/phdd/pdf/pers... , the Alma Ata Declaration³¹31. World Health Organization (WHO). Declaration of Alma-Ata. International Conference on Primary Health Care. Alma-Ata, USSR, 6-12. 1978. [acessado 2015 nov 2]. Disponível em: http://www.who.int/publications/almaata_declaration_en.pdf
http://www.who.int/publications/almaata_... , the statements of the Global Health Promotion Conferences – the Ottawa Charter, the Adelaide Recommendations, the Sundsvall Statement, the Jakarta Declaration, the Mexico Ministerial Statement³²32. Brasil. Ministério da Saúde (MS). Secretaria de Políticas de Saúde. Projeto promoção da saúde. As cartas da promoção da saúde. Brasília: MS; 2002., the Bangkok Charter³³33. World Health Organization (WHO). The Bangkok Charter for Health Promotion in a Globalized World. Bangkok. Thailand, August 2005. [acessado 2015 nov 2]. Disponível em: http://www.who.int/healthpromotion/conferences/6gchp/hpr_050829_BCHP.pdf?ua=1
http://www.who.int/healthpromotion/confe... , the Nairobi Call to Action³⁴34. World Health Organization (WHO). Nairobi Call for Action. Nairobi, 2009. [acessado 2015 nov 2]. Disponível em: http://www.who.int/healthpromotion/conferences/6gchp/hpr_050829_%20BCHP.pdf?ua=1
http://www.who.int/healthpromotion/confe... and the Helsinki Statement³⁵35. World Health Organization (WHO). The Helsinki Statement on Health in All Policies. Helsinki, 2013 [acessado 2015 nov 2]. Disponível em: http://www.healthpromotion2013.org/images/8GCHP_Helsinki_Statement.pdf
http://www.healthpromotion2013.org/image... , the regional declarations – of Santafé de Bogota³⁶36. World Health Organization (WHO). Declaration of the International Conference on Health Promotion. Santafé de Bogotá, Colombia, 1992. [acessado 2015 nov 2] Disponível em: http://www.bvsde.ops-oms.org/bvsdeps/fulltext/declarationBogota.pdf
http://www.bvsde.ops-oms.org/bvsdeps/ful... and the Caribbean Charter³⁷37. Pan American Health Organization (PAHO), World Health Organization (WHO), Caribbean Community. Caribbean Charter for Health Promotion. Port-of-Spain, Trinidad, 1993. [acessado 2015 nov 2] Disponível em: http://www.healthycaribbean.org/publications/documents/cchp.pdf
http://www.healthycaribbean.org/publicat... – and the two instances of the Brazilian National Health Promotion Policy¹⁶16. Brasil. Ministério da Saúde (MS). Política Nacional de Promoção da Saúde. Brasília: MS; 2006.^-1717. Brasil. Ministério da Saúde (MS). Portaria nº 2.446, de 11 de Novembro de 2014. Redefine a Política Nacional de Promoção da Saúde. Diário Oficial da União 2014; 12 nov..

Results and discussion

Different areas of focus for health promotion

An approach to health promotion that is initially identified refers to the proposals that emphasized changes in individual behavior, such as the Lalonde Report of 1974, which marks the early beginnings of proposals for healthcare in Canada³⁰30. Lalonde M. A new perspective on the health of Canadians.1974. [acessado 2015 nov 2]. Disponível em: http://www.hcsc.gc.ca/hppb/phdd/pdf/perspective.pdf
http://www.hcsc.gc.ca/hppb/phdd/pdf/pers... . This point of view presupposes that individuals should assume responsibilities in relation to the deleterious effects of their habits and lifestyles¹⁴14. Carvalho SR. As contradições da promoção à saúde em relação à produção de sujeitos e a mudança social. Cien Saude Colet 2004; 9(3):669-678..

Another focus, already present in the first international health promotion conference in Ottawa, 1986³²32. Brasil. Ministério da Saúde (MS). Secretaria de Políticas de Saúde. Projeto promoção da saúde. As cartas da promoção da saúde. Brasília: MS; 2002. and in the Alma Ata Declaration³¹31. World Health Organization (WHO). Declaration of Alma-Ata. International Conference on Primary Health Care. Alma-Ata, USSR, 6-12. 1978. [acessado 2015 nov 2]. Disponível em: http://www.who.int/publications/almaata_declaration_en.pdf
http://www.who.int/publications/almaata_... , emphasizes actions directed toward: transforming the ‘social determinants of the health-illness process’; creation of healthy environments; and reorientation of health services. These elements characterize the approach referred to as the ‘socioenvironmental approach’ to health promotion, which enters into a dialog with the widened concept of health as resulting from a group of social, economic, and political factors, including diet and nutrition¹⁵15. Silva KL, Sena RR, Akerman M, Belga SMM, Rodrigues AT. Intersetorialidade, determinantes socioambientais e promoção da saúde. Cien Saude Colet 2014; 19(1):4361-4370.^,3232. Brasil. Ministério da Saúde (MS). Secretaria de Políticas de Saúde. Projeto promoção da saúde. As cartas da promoção da saúde. Brasília: MS; 2002.. Consequently, the strategies proposed go beyond the indications of individualized change in behavior. However, even in the ambit of this widened approach, it is possible to identify two perspectives with distinct emphases: one, which comes close to the logic of prevention, sustained on the epidemiological models of risk factors and prevention of specific diseases; another, based on positive action for health and the construction of healthier life contexts¹⁸18. Ferreira Neto JL, Kind L, Resende MCC, Colen NS. Processos da construção da Política Nacional de Promoção da Saúde. Cad Saude Publica 2013; 29(10):1997-2007.^,1919. Silva PFA, Baptista TWF. Os sentidos e disputas na construção da Política Nacional de Promoção da Saúde. Physis 2014; 24(2):441-465.. The texts of the Brazilian National Health Promotion Policies (NHPPs) are an example of how these two logics coexist, because they refer to specific illnesses or problems and provide a wider focus of the health-illness process – especially the 2014 NHPP¹⁷17. Brasil. Ministério da Saúde (MS). Portaria nº 2.446, de 11 de Novembro de 2014. Redefine a Política Nacional de Promoção da Saúde. Diário Oficial da União 2014; 12 nov..

Polarization between these different points of view depoliticizes the debate, since health promotion, although it is not restricted to the sphere of the individual, cannot ignore the importance of this perspective¹⁹19. Silva PFA, Baptista TWF. Os sentidos e disputas na construção da Política Nacional de Promoção da Saúde. Physis 2014; 24(2):441-465.. Thus, it is not a case of reiterating the classic dichotomies between individualized and socio-environmental approaches, but of recognizing how the different proposals contribute to understanding of conflict of interest.

The idea-inventory of health promotion, and the politics arising from it, have given rise to different and even antagonistic opinions in the academic debate between those who consider them to be transforming factors or conservers of the health status quo (marked by inequities of different types, including of power). This antagonism can indicate the ambiguous character of certain assumptions, the de-politicization of certain debates, or the non-deepening of subjects such as the relationship between capitalism and health¹⁴14. Carvalho SR. As contradições da promoção à saúde em relação à produção de sujeitos e a mudança social. Cien Saude Colet 2004; 9(3):669-678.. The 2014 NHPP¹⁷17. Brasil. Ministério da Saúde (MS). Portaria nº 2.446, de 11 de Novembro de 2014. Redefine a Política Nacional de Promoção da Saúde. Diário Oficial da União 2014; 12 nov. seems to make progress in this aspect when, for example, it analyzes themes such as manner of consumption and production from the point of view of sustainable development.

Principle strategies, values and principles of the policies

The actions proposed in the Brazilian health promotion policies¹⁶16. Brasil. Ministério da Saúde (MS). Política Nacional de Promoção da Saúde. Brasília: MS; 2006.^,1717. Brasil. Ministério da Saúde (MS). Portaria nº 2.446, de 11 de Novembro de 2014. Redefine a Política Nacional de Promoção da Saúde. Diário Oficial da União 2014; 12 nov. are based on epidemiological data used in the analysis of the ‘social determinants of health’. The prevalence of CNCDs is correlated with: The present profile of diet and physical activity; the use of alcohol and tobacco, and the conditions of being overweight, and obesity.

In the 2006 NHPP¹⁶16. Brasil. Ministério da Saúde (MS). Política Nacional de Promoção da Saúde. Brasília: MS; 2006., the specific actions highlighted for achieving promotion of health directly related to CNCDs are: healthy diet; practice of physical activity; prevention and control of smoking; and reduction of morbimortality arising from abusive use of alcohol and other drugs. Distinctions can be identified in the NHPP of 2014, such as: adoption of a logic of ‘priority subjects’; inclusion of the subject of permanent education; and, further, re-characterization of terms. While the 2006 NHPP used the term ‘prevention’ with a focus on illness, the 2014 NHPP uses terms such as: promoting health habits; articulating; and mobilizing. Further to this, it makes explicit the fundamental values of the policy, which are: solidarity, happiness, ethics, humanization, respect for diversity, co-responsibility, social justice, and social inclusion/empowerment¹⁷17. Brasil. Ministério da Saúde (MS). Portaria nº 2.446, de 11 de Novembro de 2014. Redefine a Política Nacional de Promoção da Saúde. Diário Oficial da União 2014; 12 nov..

The 2014 NHPP enunciates the adequate and health food (AHF) as a priority theme, a conception that originated in the ambit of the debates on Food and Nutrition Security (FNS) and that was described in the National Food and Nutrition Security Policy (NFNSP). This refers to adequacy of diet in an amplified perspective, not only biological, but cultural, social, economic and environmental³⁸38. Brasil. Presidência da República. Decreto 7.272, de 25 de agosto de 2010. Regulamenta a Lei no 11.346, de 15 de setembro de 2006, que cria o Sistema Nacional de Segurança Alimentar e Nutricional - SISAN com vistas a assegurar o direito humano à alimentação adequada, institui a Política Nacional de Segurança Alimentar e Nutricional - PNSAN, estabelece os parâmetros para a elaboração do Plano Nacional de Segurança Alimentar e Nutricional, e dá outras providências. Diário Oficial da União 2010; 26 ago.. The adoption of this new terminology, to the detriment of simply ‘healthy diet’ used in the 2006 NHPP, consolidates a focus that was already present in the first version of the NHPP, linking actions for promotion of healthy diet to FNS and to the Human Right to Adequate Food (RtoAF). Further, it conceptually brings the 2014 NHPP closer to other policies such as the NFNSP³⁸38. Brasil. Presidência da República. Decreto 7.272, de 25 de agosto de 2010. Regulamenta a Lei no 11.346, de 15 de setembro de 2006, que cria o Sistema Nacional de Segurança Alimentar e Nutricional - SISAN com vistas a assegurar o direito humano à alimentação adequada, institui a Política Nacional de Segurança Alimentar e Nutricional - PNSAN, estabelece os parâmetros para a elaboração do Plano Nacional de Segurança Alimentar e Nutricional, e dá outras providências. Diário Oficial da União 2010; 26 ago., the National Food and Nutrition Policy (NFNP)³⁹39. Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Política Nacional de Alimentação e Nutrição. Brasília: MS; 2012., and, further, the Dietary Guidelines for the Brazilian population, of 2014⁴⁰40. Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Guia alimentar para a população brasileira. 2ª ed. Brasília: MS; 2014..

The 2014 NHPP¹⁷17. Brasil. Ministério da Saúde (MS). Portaria nº 2.446, de 11 de Novembro de 2014. Redefine a Política Nacional de Promoção da Saúde. Diário Oficial da União 2014; 12 nov., and also the NFNP³⁹39. Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Política Nacional de Alimentação e Nutrição. Brasília: MS; 2012. and the NFNSP³⁸38. Brasil. Presidência da República. Decreto 7.272, de 25 de agosto de 2010. Regulamenta a Lei no 11.346, de 15 de setembro de 2006, que cria o Sistema Nacional de Segurança Alimentar e Nutricional - SISAN com vistas a assegurar o direito humano à alimentação adequada, institui a Política Nacional de Segurança Alimentar e Nutricional - PNSAN, estabelece os parâmetros para a elaboração do Plano Nacional de Segurança Alimentar e Nutricional, e dá outras providências. Diário Oficial da União 2010; 26 ago., propose actions for widening of the supply and access to AHF, regulation of advertising and of supply of foods in schools, workplaces, among others, and educational strategies. The different emphasizes given to the conditional factors relate to various types of measure. If the emphasis falls on the ‘socioenvironmental’ dimension, the actions proposed aim to alter it; at the same time, if it is concentrated on individual choices, the outlook is to modify practices, in particular through access to information. Although they are equally important, these different angles of focus have differentiated implications for the debate on conflict of interest. The emphasis on individual decisions on consumption profiles can, for example, leave out of account the analysis of the strong influence that market practices (including the various forms of advertising and marketing of food products) and commercial strategies exercise on consumption. At the same time, it is not possible to promote FNS, reduce poverty, and guarantee RtoAF, in harmony with the principles and values that guide the respective policies, without bringing into evidence the effects of those strategies, from production to consumption of foods, and without regulating them.

The practices of the commercial private sector refer both to ‘end’ activities (selling of products and stimulation of their consumption) and also to policy practices, such as the block on government measures that directly harm their interest. Due to the political and economic power that it has, this sector has been capable of holding back progress, especially in measures of a regulatory nature, and of impeding approval of legislation, delaying its implementation or rolling back measures already implemented. Some examples of these embargoes have been: the defeat of the public power, in 2010, in its initiative to regulate advertising of unhealthy foods and beverages¹²12. Henriques P, Dias PC, Burlandy L. A regulamentação da propaganda de alimentos no Brasil: convergências e conflitos de interesses. Cad Saúde Pública 2014: 30(6):1219-1228.; the threat of retrograde steps in the labelling of GM foods, arising from Draft Law 34/2015, which aims to exempt food producers from informing the consumer about the presence of GM components when they are present in a percentage of less than 1% of the total composition of the food product⁴¹41. Brasil. Senado Federal. Projeto de Lei da Câmara nº 34, de 2015. [acessado 2016 jan 26]. Disponível em: http://www25.senado.leg.br/web/atividade/materias/-/materia/120996
http://www25.senado.leg.br/web/atividade... ; and the timidity of the public power in the regulation of abusive use of pesticides, as in the case of the National Program for Reduction of Use of Pesticides, one of the main objectives of which is to expand and strengthen the production of organic products and an agro-ecological base and reduce the use of poison in plantations – formulation of this policy was concluded in 2014, but it has so far not been launched⁴²42. Brasil. Presidência da República. Comissão nacional de agroecologia e produção orgânica. Programa Nacional de Redução de Agrotóxicos. 2014. [acessado 2016 jan 26]. Disponível em: http://www.agroecologia.org.br/files/importedmedia/pronara-programa-nacional-de-reducao-de-agrotoxicos-aprovado-por-merito-na-cnapo-em-agosto-de-2014.pdf
http://www.agroecologia.org.br/files/imp... . These situations signal the difficulty of regulating and modifying the ‘socioenvironmental conditioning factors’ of food practices.

Governmental documents highlight the importance of regulatory measures for dealing with CNCDs and for promotion of FNS⁴³43. Brasil. Ministério da Saúde (MS). Plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis (DCNT) no Brasil 2011-2022. Brasília: MS; 2011.^,4444. Brasil. Câmara Interministerial de Segurança Alimentar e Nutricional (CAISAN). Estratégia Intersetorial de Prevenção e Controle da Obesidade: recomendações para estados e municípios. Brasília: CAISAN; 2014.. However, the barriers to making this a reality are innumerable, since they have repercussions in the political and economic interests of institutions inside and outside the government, which superimpose financial interests on the objectives and priorities considered as the basis for the government’s policies themselves.

The practices of the private sector that supposedly have convergence with public policies relate, among other things, to: provision of services to governments; voluntary agreements (which in general establish very flexible targets or targets that have already been achieved); and partnerships for educative campaigns. These types of relationships are not always recognized as an interference by the commercial private sector that diverges from or creates obstacles to the interests and missions of governments. Thus, it is in this group of practices that conflicts of interest occur in a more evident form, because the commercial private sector has an interest in limiting actions of governments to measures of this type, and by doing so position itself as a ‘partner’ of the public power. In this case, the group of institutional practices, products and policies of that sector are overlooked – those that harm the principles and objectives of the public policies and which could compromise the collective interest or improperly influence the performance of the public function.

The approach to conflicts of interest and the relationships with the commercial private sector

By analyzing the construction of the concept of promotion of health in a historic perspective, Lopes et al.⁴⁵45. Lopes MSV, Saraiva KRO, Fernandes AFC, Ximenes LB. Análise do conceito de promoção da saúde. Texto Contexto Enferm 2010; 19(3):461-468. indicate how the international forums and organizations that deal with the subject, including those connected to the United Nations (UN), such as the WHO, have influenced the terms of national health policies in Brazil.

In a UN document that orients its relationship with other sectors (made explicit by the term ‘partnerships’), the private sector is defined as ‘all individuals, associations, companies and businesses with aims for profit; and philanthropic associations, coalitions, corporations and foundations’⁴⁶46. United Nations (UN). Cooperation between the United Nations and all relevant partners, in particular the private sector. Report of the Secretary-General to the General Assembly. Item 39 of the provisional agenda: Towards global partnerships. UN Doc. A/56/323. New York, 28 August, 2001.. This definition does not distinguish within the private sector entities that are for profit, commercial or ‘non-profit’, a distinction found in subsequent documents of specific instances of the UN, such as the Standing Committee on Nutrition which, in 2006, established its policy in relation to engagement of the private sector⁴⁷47. United Nations (UN). Standing Committee on Nutrition (SCN). SCN Private Sector Engagement Policy. Geneva, March 2006. [acessado 2016 jan 26]. Disponível em: http://www.unscn.org/files/Structure/SCN_and_the_Private_Sector/SCN_Private_Sector_Engagement_Policy.pdf
http://www.unscn.org/files/Structure/SCN... . The document recognizes that the private sector presents opportunities and risks for the objectives of the committee itself and presents a protocol of measures to be taken so that conflicts of interest with this sector are adequately administered. In this document, the private sector is defined as the sector that aims for profit, independently of the scale of the companies or the type of ownership (private, collective, by employees or by the state), whether such companies are formally legalized or not. Organizations which, although denominated ‘non-profit’ in their legal basis, are financed by, provide services to or argue the cases of for-profit organizations are also considered to be part of the private sector. The document makes explicit that there is conflict of interest when a secondary interest, and/or the purposes of organizations or individuals, influence the scope of the primary interests of the committee itself, or of the terms of its mandate, or, further, of its institutional vision which consists in achieving a world free of hunger and of malnutrition⁴⁷47. United Nations (UN). Standing Committee on Nutrition (SCN). SCN Private Sector Engagement Policy. Geneva, March 2006. [acessado 2016 jan 26]. Disponível em: http://www.unscn.org/files/Structure/SCN_and_the_Private_Sector/SCN_Private_Sector_Engagement_Policy.pdf
http://www.unscn.org/files/Structure/SCN... . The committee dedicated a special edition of its magazine to dealing with possible forms of engagement by governments with the commercial private sector⁴⁸48. United Nations (UN). SCN News. Nutrition and Business. How to Engage. 39(1). Genève: UN/SCN, 2011..

In the ambit of prevention of CNCDs, documents of the UN and the WHO differentiate the action of the sector referred to as ‘civil society’ (in the provision of services and political mobilization) from the participation of the commercial private sector (industrial and other companies) which takes place, for example, through reformulation of food products (reduction of the level of trans fat, salt, sugar), health promotion actions, production of medications and guarantee of ‘responsible’ marketing⁴⁹49. United Nations (UN). Summary of the informal interactive hearing with representatives of nongovernmental organizations, civil society organizations, academia and the private sector, to provide an input to preparatory process of the 2011 High-level Meeting on the Prevention and Control of Non-communicable Diseases. Washington: UN; 2011.

50. United Nations (UN). General Assembly. Political declaration of the high-level meeting of the general assembly on the prevention and control of non-communicable diseases. Washington: UN; 2011.^-5151. World Health Organization (WHO). Global status report on non communicable diseases 2010. Geneva: WHO; 2011..

In a UN hearing on CNCDs held in 2011, the need for involvement of all the sectors in the process was emphasized. At the same time, there was insistence on the importance of clarifying the role of each one, to ensure that potential conflicts of interest are administered appropriately, including the development, by the signatory countries, of protocols that can facilitate this analysis⁴⁹49. United Nations (UN). Summary of the informal interactive hearing with representatives of nongovernmental organizations, civil society organizations, academia and the private sector, to provide an input to preparatory process of the 2011 High-level Meeting on the Prevention and Control of Non-communicable Diseases. Washington: UN; 2011.. The political statement of that meeting explicitly indicated that the fundamental conflict of interest between the tobacco industry and public health should be recognized, and also argued that public health policies should be protected from the influence of that industry. However, it did not mention the conflict of interest with the food and beverage products industry⁵⁰50. United Nations (UN). General Assembly. Political declaration of the high-level meeting of the general assembly on the prevention and control of non-communicable diseases. Washington: UN; 2011..

In the global health promotion documents, the direct mention of the role of the ‘private sector’ appeared for the first time in the Jakarta Declaration (1997), prepared at the fourth Global Health Promotion Conference, the first one that was hosted in a developing country. This event marked the start of the officialized participation of the private sector in these forums, and also had its own separate space for preparation of a statement about that sector’s interests (the Jakarta Declaration on the Private Sector)⁵²52. World Health Organization (WHO). Jakarta Statement on the Private Sector. [acessado 2015 nov 2]. Disponível em: http://www.who.int/healthpromotion/conferences/previous/jakarta/statements/private_sector/en/
http://www.who.int/healthpromotion/confe... . Previous conferences had emphasized issues more related to the public sector – such as that of Adelaide, Australia, in 1988, the main subject of which was healthy public policies³²32. Brasil. Ministério da Saúde (MS). Secretaria de Políticas de Saúde. Projeto promoção da saúde. As cartas da promoção da saúde. Brasília: MS; 2002.; that of Sundsvall in Sweden, in 1991, which dealt with subjects such as environments favorable to health and strengthening of social action³²32. Brasil. Ministério da Saúde (MS). Secretaria de Políticas de Saúde. Projeto promoção da saúde. As cartas da promoção da saúde. Brasília: MS; 2002.; and the Caribbean Charter, of 1993, which highlighted alliances with the media, a commercial sector considered important due to the influence that it exercises on political processes³⁷37. Pan American Health Organization (PAHO), World Health Organization (WHO), Caribbean Community. Caribbean Charter for Health Promotion. Port-of-Spain, Trinidad, 1993. [acessado 2015 nov 2] Disponível em: http://www.healthycaribbean.org/publications/documents/cchp.pdf
http://www.healthycaribbean.org/publicat... .

As from Jakarta, the private sector has participated systematically in global conferences on health promotion and been active in preparation of the reports and strategies. The Bangkok Conference (2005) already explicitly recognized the penetration of the private sector in public health. The most recent conference, held in Helsinki (2013) evidences the relationships between all the sectors for achieving positive results in health, including the private sector. However, for the first time governments are called upon to establish measures for dealing with conflict of interest to protect policies from commercial distortions, interests and influences. Part of the challenges indicated refers to the political power of companies and the possibility of their affecting governmental capacity to protect and promote the population’s health. Specifically highlighted are the interests of powerful economic forces that resist regulation. In the document, the approach to health in all the policies is a concrete response to these challenges, with the potential it represents for providing parameters for regulation and practical tools that combine social targets, health targets and equality targets, with economic development, and which approach conflict of interest with transparency – which is of course not sufficient, but is essential. It is considered that this point of view can facilitate dealing with the relationships between the sectors involved, including the private sector, in the sense of protecting policies, missions and values against divergences that would separate them from the public interest, contributing positively to health outcomes³⁵35. World Health Organization (WHO). The Helsinki Statement on Health in All Policies. Helsinki, 2013 [acessado 2015 nov 2]. Disponível em: http://www.healthpromotion2013.org/images/8GCHP_Helsinki_Statement.pdf
http://www.healthpromotion2013.org/image... .

In the ambit of Brazilian policies, the 2014 NHPP recommends mechanisms that give visibility to the conflicts of interest already foreseen in the 2006 NHPP, such as the constitution of its Management Committee. It is sitting and substitute members must declare non-existence of conflict of interest with their activities in the debate on the subjects relating to this space and, if a conflict of interest exists, they must abstain from debating and deciding about the subject⁵³53. Brasil. Ministério da Saúde (MS). Portaria 1.409, de 13 de junho de 2007. Institui Comitê Gestor da Política Nacional de Promoção da Saúde. Diário Oficial da União 2007; 14 jun.. The subject of conflict of interest is also dealt within the specific objectives of the NHPP, under the following statement: To foster discussions on modes of consumption or production that are in conflict of interest with the principles and values of promotion of health, and which increase vulnerabilities and risks to health. This statement suggests, on the other hand, a conceptual distortion in relation to the frames of reference of conflict of interest and, on the other hand, a lacuna of more explicit criteria for characterizing situations of conflict of interest, especially in the case of commercial sectors that could compromise the principles and values specified in the policy.

Relationships between the public and private sectors referred to as ‘partnerships’

The notion of integrated activity of various sectors (governmental, society, commercial private) and multiple accountability, whether for problems or for solutions, has been present in the inventory of ideas of health promotion since Alma Ata, even though the focus may have fallen on actions of governments³²32. Brasil. Ministério da Saúde (MS). Secretaria de Políticas de Saúde. Projeto promoção da saúde. As cartas da promoção da saúde. Brasília: MS; 2002.. The term ‘partnership’ appears for the first time in the Alma Ata Declaration, referring to mutual support between countries for primary care and healthcare in general³¹31. World Health Organization (WHO). Declaration of Alma-Ata. International Conference on Primary Health Care. Alma-Ata, USSR, 6-12. 1978. [acessado 2015 nov 2]. Disponível em: http://www.who.int/publications/almaata_declaration_en.pdf
http://www.who.int/publications/almaata_... . The Ottawa Charter³²32. Brasil. Ministério da Saúde (MS). Secretaria de Políticas de Saúde. Projeto promoção da saúde. As cartas da promoção da saúde. Brasília: MS; 2002. does not use the term, but indicates the same idea through the notion of ‘intersectoral actions’. As from that time, intersectoral actions and partnerships have become a fundamental prerequisite for characterization of an action as promoting health. The Adelaide Recommendations state that cooperation should occur between the various sectors, but also within a single area³²32. Brasil. Ministério da Saúde (MS). Secretaria de Políticas de Saúde. Projeto promoção da saúde. As cartas da promoção da saúde. Brasília: MS; 2002.. Sometimes the term ‘sector’ refers to fields of activity (health, environment, etc.), but, up to the Jakarta Conference (1997), these ‘sectors’ refer fundamentally to governments. It is at this moment that there is an important inflection in terms of suggesting the commercial private sector as a partnership in health promotion strategies. The Bangkok Charter refers to the formation of alliances between public, private, non-governmental and international organizations, and also with civil society, to create sustainable health promotion actions³³33. World Health Organization (WHO). The Bangkok Charter for Health Promotion in a Globalized World. Bangkok. Thailand, August 2005. [acessado 2015 nov 2]. Disponível em: http://www.who.int/healthpromotion/conferences/6gchp/hpr_050829_BCHP.pdf?ua=1
http://www.who.int/healthpromotion/confe... .

Reiterating this analysis, Lopes et al.⁴⁵45. Lopes MSV, Saraiva KRO, Fernandes AFC, Ximenes LB. Análise do conceito de promoção da saúde. Texto Contexto Enferm 2010; 19(3):461-468. identified that the need for mediation of health with other sectors, including the constitution of ‘partnerships’ and ‘alliances’ of governments with civil society and the private sector, contributed to shaping of the concept of health promotion. In the inventory of ideas of health promotion, the scope of the objectives of health requires a coordinated action by all those implicated (sectors of government, as well as health, communications media, society organizations and the commercial sector) and, similarly, demands an integrated approach to the processes of social and economic development with health.

Coordinated actions and integrated approaches are intimately associated with the principle of intersectoriality, the operationalization of which takes place, according to the terms used in the Brazilian documents, through new ‘partnerships’ and ‘alliances’ with unions, segments of commerce, industry, academic associations, and media – among others⁴³43. Brasil. Ministério da Saúde (MS). Plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis (DCNT) no Brasil 2011-2022. Brasília: MS; 2011.. The concept that guides the debate on health promotion is that the intersectoriality refers to the process of articulation of knowledge, potential and experiences of subjects, groups and sectors in the construction of shared interventions, establishing links, co-responsibility and co-management for common objectives¹⁷17. Brasil. Ministério da Saúde (MS). Portaria nº 2.446, de 11 de Novembro de 2014. Redefine a Política Nacional de Promoção da Saúde. Diário Oficial da União 2014; 12 nov.. Thus, a strategy of convergence is proposed which includes the commercial private sector⁵⁴54. Malta DC, Gosch CS, Buss P, Rocha DG, Rezende R, Freitas PC, Akerman M. Doenças crônicas Não transmissíveis e o suporte das ações intersetoriais no seu enfrentamento. Cien Saude Colet 2014; 19(11):4341-4350.. And in consequence, intersectoral activity is a central question for the debate on conflict of interest, but in the ambit of health promotion, the subject has not been problematized under this focus. As has been seen, this discussion appears for the first time only in the Helsinki Statement in 2013³⁵35. World Health Organization (WHO). The Helsinki Statement on Health in All Policies. Helsinki, 2013 [acessado 2015 nov 2]. Disponível em: http://www.healthpromotion2013.org/images/8GCHP_Helsinki_Statement.pdf
http://www.healthpromotion2013.org/image... .

The 2014 NHPP presupposes that it is a role of all the levels of government to make possible partnerships with international organizations, government and non-government organizations, including the private sector and civil society, for the strengthening of promotion of health in the country¹⁷17. Brasil. Ministério da Saúde (MS). Portaria nº 2.446, de 11 de Novembro de 2014. Redefine a Política Nacional de Promoção da Saúde. Diário Oficial da União 2014; 12 nov.. The possibility of articulation with the commercial private sector appears in a more explicit way in the priority subject of promotion of sustainable development¹⁷17. Brasil. Ministério da Saúde (MS). Portaria nº 2.446, de 11 de Novembro de 2014. Redefine a Política Nacional de Promoção da Saúde. Diário Oficial da União 2014; 12 nov.. This theme constitutes a particularly complex space, considering the divergences of conceptions and focus on the relationship between development and health⁵⁵55. Nogueira RP. Perspectivas Críticas acerca da Relação entre Saúde e Desenvolvimento com Foco nos Países Bric. Porto Alegre: Análise Econômica 2012; 30:75-95..

The interdependence between health and socioeconomic development is highlighted as a prerequisite for health promotion, and has been a central theme in documents such as the regional declarations of Bogota³⁶36. World Health Organization (WHO). Declaration of the International Conference on Health Promotion. Santafé de Bogotá, Colombia, 1992. [acessado 2015 nov 2] Disponível em: http://www.bvsde.ops-oms.org/bvsdeps/fulltext/declarationBogota.pdf
http://www.bvsde.ops-oms.org/bvsdeps/ful... and the Caribbean³⁷37. Pan American Health Organization (PAHO), World Health Organization (WHO), Caribbean Community. Caribbean Charter for Health Promotion. Port-of-Spain, Trinidad, 1993. [acessado 2015 nov 2] Disponível em: http://www.healthycaribbean.org/publications/documents/cchp.pdf
http://www.healthycaribbean.org/publicat... , which implies considering that economic processes should carry out a positive conditioning influence on conditions of life in such a way as to favor health and not illness. The terms of these proposals indicate that, if on the one side the bases of development/economic growth can interfere positively or negatively in the population’s health, this situation of health, in turn, can contribute, in a two-way-street, to growth or to stagnation of the economy⁵⁶56. Marcondes WB. A convergência de referências na promoção da saúde. Saúde Soc 2004; 13(1):5-13..

In the ambit of this study it is appropriate to problematize the use, itself, of these terms in the documents analyzed, in the light of the reflections on conflict of interest, to consider the group of companies that comprise the commercial private sector and analyze to what extent they are guided by the same principles, values and objectives of a State policy such as the NHPP²²22. Gomes FS. Conflito de interesse em alimentação e nutrição. Cad Saude Publica 2015; 31(10):2039-2046.^,2525. Castro IRR. Relação público-privado, conflito de interesses e a agenda regulatória para a consolidação da democracia. Ensaios e Diálgos em Saúde Coletiva 2015; 1:74-80..

The accountability shared with the private sector reiterates the establishment of ‘partnerships’ in the construction of solutions. However, such partnerships are treated as relationships between entities which in principle would have common objectives, and shared principles and values. Further, they presuppose horizontal relationships between political subjects with strong asymmetry of power.

In the analysis of the conditions of possibility and of the context in which this discourse was constructed, the influence of the proposals for retraction of action by the State, present in the international scenario in the 1990s, is highlighted. It is in this context that the discussion on PPPs gains importance in the UN, strongly influenced by the World Bank, this term coming to be defined as the relationship between state and non-state participants that agree to work together to achieve common objectives. When analyzing the PPPs proposed by the UN in the ambit of global public health, Velaskes⁵⁷57. Velaskes G. Public-private partnerships in global health: putting business before health? South Centre. Genève: WHO; 2014. Research Papers 49. indicates that they have not been put into effect and that conflicts of interest are present in the political spaces and consultative committees that define them.

The outlook for achieving common objectives in health and nutrition through PPPs needs to be problematized in the light of the effects of sale/marketing of ultra-processed products, and pesticides, on the increase of CNCDs in Brazil and worldwide⁶6. Moodie R, Stuckler D, Monteiro CA, Sheron N, Neal B, Thamarangsi T, Lincoln T, Casswell S. Profits and pandemics: prevention of harmful effects of tobacco, alcohol, and ultra-processed food and drink industries. Lancet 2013; 381(9867):670-679.^,1313. Carneiro FF, Augusto LGS, Rigotto RM, Friedrich K, Búrigo AC. Dossiê ABRASCO: um alerta sobre os impactos dos agrotóxicos na saúde. Rio de Janeiro, São Paulo: EPSJV, Expressão Popular; 2015.^,5858. Louzada MLC, Baraldi LG, Steele EM, Martins APB, Canella DS, Claude-Moubarac JL, Bertazzi R, Cannon G, Afshin A, Imamura F, Mozaffarian D, Monteiro CA. Consumption of ultra-processed foods and obesity in Brazilian adolescents and adults. Prev Med 2015; 81:9-15.. Such companies have been contributing to a profile of food practices and situations of food insecurities that the NHPP aims to revert.

Thus, it is questioned whether there are common objectives between the ‘partners’, and it is worth signaling the contradictory element expressed in the documents which, on the other hand, recognize that practices of the private sector have been contributing negatively to the situation of health (and, thus, are part of the problem), but do not indicate actions capable of restraining the activity of these sectors. Paradoxically, they propose relationships of partnership without considering the asymmetries of power, of values and of practices, and ignore the fact that effective measures to reserve this situation are irreconcilable with market logic and interests.

Conclusions

The documents analyzed do not present specific proposals for dealing with conflict of interest and do not go deeply into the subject. However, the various approaches to health promotion that have been identified (individualized, socioenvironmental, health prevention and positive health) can sustain different strategies of action that have differentiated implications for the debate on conflict of interest. Depending on the way in which the actions and practices of the commercial private sector are considered in these proposals, conflicts of interest may be more or less in evidence and, consequently, treated in a more or less politicized way. In the documents analyzed, this de-politicization was identified in narratives that mask the existing relationships of power and omit asymmetries and antagonistic interests.

By recognizing the importance of broad political pacts and partnerships that articulate a heterogeneous range of political institutions and subjects, the strategies of health promotion could give rise to political compositions between institutions with different power of influence in the decision process and, principally, with vocations, principles, values, objectives and interests that are sometimes opposed and irreconcilable. The debate on conflict of interest suffers from a de-politicization when such asymmetries and oppositions between those who are parts of the so-called PPPs are not made explicit, or when practices of the commercial private sector that injure objectives, principles and values of the very health promotion policies themselves are left out of account.

The approach to health promotion associated with guarantee of Food and Nutrition Security, Adequate and Healthy Food and the Human Right to Adequate Food, present in the Brazilian National Health Promotion Policy, and the principles, values and strategies that have been constructed in Brazil in these respective environments of political action, are incompatible with the products and market practices of the commercial private sector. From the point of view of conflict of interest, there is a need to reflect on the (im)possibility of sharing of power with this sector, due to the principles and values established by the policy itself. Public-Private Partnerships are only possible when the values and objectives that underlie the policies and the objects of the partnerships converge with the primary mission of the parties. If this is not so, they become inconceivable as such, whatever name may be given to them, and establish themselves as relationships with appearance of partnership, but which are asymmetric and permeated by conflicts of interest.

The policies analyzed do not have concrete criteria and procedures for dealing with situations of conflicts of interest in the process of formulation and implementation of actions. When the conflicts of interest themselves are not recognized in a transparent manner, as proposed in the Helsinki Statement, the relationships with sectors whose practices and products injure the principles that the very policy itself establishes for health promotion and promotion of AHF will always be de-politicized and ‘naturalized’.

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