Abstract

This paper aims to understand the meanings of food and nutrition policies for beneficiary mothers and for technicians designing and implementing said policies. The Grounded Theory method was employed. The data collection techniques adopted were the semi-structured interview and the focus group. The participants were beneficiaries of food and nutrition programs, with a minimum two-year experience, and technicians with five-year experience in designing or implementing these policies and programs. Food and nutrition policies are conceived and managed under a market logic, which has required an institutional framework that adopted this commercial model to provide public services, which is implemented in the scheme of outsourcing third parties, especially private companies, who implement these policies to achieve financial profitability. The market is imposed as the benchmark for the State’s actions, and, therefore, the State’s action is limited the oversight of outsourced actions, and food policies become devices for the diversion of public resources to the private sector.

Key words
State; Food and nutrition programs and policies; Nutrition in public health; Food assistance; Outsourced services

Introduction

According to the Food and Agriculture Organization of the United Nations (FAO), 795 million people globally, of which 34.3 million in Latin America and the Caribbean, suffered from chronic hunger in the 2014-2016 period¹1 Food and Agriculture Organization (FAO), Fondo Internacional de Desarrollo Agricola (FIDA), Programa Mundial de Alimientos (PMA). El estado de la inseguridad alimentaria en el mundo 2015 [Internet]. Roma, Italia; 2015. [citado 2016 Oct 23]. Disponible en: http://www.fao.org/3/a-i4646s.pdf
http://www.fao.org/3/a-i4646s.pdf... . Hunger has been reduced by only 21.4%¹1 Food and Agriculture Organization (FAO), Fondo Internacional de Desarrollo Agricola (FIDA), Programa Mundial de Alimientos (PMA). El estado de la inseguridad alimentaria en el mundo 2015 [Internet]. Roma, Italia; 2015. [citado 2016 Oct 23]. Disponible en: http://www.fao.org/3/a-i4646s.pdf
http://www.fao.org/3/a-i4646s.pdf... during the 20 years since the 1990-1992 base period. Colombia faces a great challenge because the phenomena of deficits of a significant proportion of its children and young people remain unsolved, mainly expressed in stunting, the deficit of micronutrients such as iron, zinc, and vitamin A²2 Instituto Nacional de Bienestar Familiar (ICBF), Min. Protección Social, Instituto Nacional de Salud (INS). Encuesta Nacional de la Situación Nutricional 2010 [Internet]. Bogotá: ICBF, Ministerio de la Protección Social, INS; 2011. [citado 2016 Oct 23]. Disponible en: https://www.icbf.gov.co/icbf/directorio/portel/libreria/php/03.03081103.html
https://www.icbf.gov.co/icbf/directorio/... , while the country is facing the phenomenon of Chronic Non-Communicable Diseases (NCDs), which mainly affect the adult population³3 Organización Panamericana de Salud (OPS). Salud en la Américas 2012: volumen de países. Colombia. [Internet]. 2012. [citado 2016 Oct 23]. Disponible en: http://www.paho.org/saludenlasamericas/index.php?option=com_docman&task=doc_view&gid=197&Itemid=
http://www.paho.org/saludenlasamericas/i... . This double burden of malnutrition⁴4 Sarmiento O, Parra D, González S, González I, Forero A. The dual burden of malnutrition in Colombia. Am J Clin Nutr 2014; 100(6):1628S-1635S. occurs amid a situation of poverty and deep inequality in the distribution of wealth, which generates a social gradient that is expressed in inequities in nutritional status, given that the prevalence of growth retardation of children under five years of age in level 1 of the Sisbén (System for the Identification of Potential Beneficiaries of Social Programs) was 16.8%, while it was 9.1%²2 Instituto Nacional de Bienestar Familiar (ICBF), Min. Protección Social, Instituto Nacional de Salud (INS). Encuesta Nacional de la Situación Nutricional 2010 [Internet]. Bogotá: ICBF, Ministerio de la Protección Social, INS; 2011. [citado 2016 Oct 23]. Disponible en: https://www.icbf.gov.co/icbf/directorio/portel/libreria/php/03.03081103.html
https://www.icbf.gov.co/icbf/directorio/... at level 4 or more.

In this overview, the Food and Nutrition Policies and Programs (PPAN) are the State’s response to facing the nutritional duality endured by the population. However, within the framework of a neoliberal development model of globalization and a more significant positioning of the private sector and transnational corporations’ interests, these policies can legitimize a residual conception of the State and, therefore, the social sphere⁵5 P. Tres retos para entender la acción pública hoy en día. In: Muller P. Las políticas públicas. 3ª ed. Bogotá: Universidad Externado de Colombia; 2010. p. 163-90.^,66 Sousa GW. Como reinventar a gestão e o funcionamento dos sistemas públicos e organizações estatais? Cien Saude Colet 2008; 13(Supl. 2):2019-2021..

Although hunger and food insecurity have gained a privileged place on the public agenda and, consequently, various policies have proliferated to address these phenomena, the population’s food and nutritional situation is not improving to the same extent. Furthermore, the studies that evaluate the effects of PPANs are predominantly quantitative⁷7 Fung C, McIsaac J, Kuhle S, Kirk S, Veugelers P. The impact of a population-level school food and nutrition policy on dietary intake and body weights of Canadian children. Prev Med 2013; 57(6):934-940.

8 Moffitt R, Ribar D. Rasch Analyses of Very Low Food SecurityAmong Households and Children in the Three City Study. Southern Economic Journal 2016; 82(4):1123-1146.

9 John J, Wolfenstetter S, Wenig C. An economic perspective on childhood obesity: Recent findings on cost of illness and cost effectiveness of interventions. Nutrition 2012; 28(9):829-839.^-1010 Erdöl Ş, Mazzucco W, Boccia S. Cost Effectiveness Analysis of Childhood Obesity Primary Prevention Programmes: A Systematic Review. Epidemiology Biostatistics and Public Health. 2014; 11(3):e94161-10., concerning food consumption, anthropometric, and biochemical variables. However, little has been investigated about the experience of the subjects who interact with the PPANs. That is why this research aimed to understand the meanings of food and nutrition policies for a group of beneficiaries and the technicians involved in their design and implementation.

The findings presented in this manuscript are nested in a framework investigation entitled “The meanings in the tension of food and nutrition policies for a group of technical beneficiaries in two Municipalities of Antioquia. ”¹¹11 Mancilla López L. Los signficados en tensión de las políticas de alimentación y nutrición para un grupo de beneficiarios y de técnicos en dos municipioos de Antioquia [tesis]. Medellín: Universidad de Antioquia; 2017.

Methods

The Grounded Theory (GT) method was used, based on symbolic interactionism¹²12 Glaser BG, Strauss AL. Generating Theory. In: Glaser BG, Strauss AL. The Discovery of Grounded Theory: strategies for qualitative research. New York: Aldine de Gruyter; 1967. p. 21-44.. Likewise, we accepted the constructivist approach of Charmaz GT, which assumes a relativistic epistemology, views knowledge as socially produced, recognizes multiple views of both the participants and the researcher, and adopts a reflective position towards the actions and situations of its own and the participants, and the analytical constructions by us researchers. The constructivist perspective considers research as a process and a product, which develops under pre-existing conditions, arises from emergent situations, and is influenced by the perspectives, privileges, location, interaction, and geographic location of researchers¹³13 Charmaz K. Shifting the Grounds. Constructivist Grounded Theory Methods. In: Corbin J, Clarke A, Charmaz K, Stern P, Bowers B, Morse JM, editors. Developing Grounded Theory The Second Generation. California: Left Coast Press; 2009. p. 127-147..

Charmaz defines GT as a qualitative research method in which collection and analysis inform each other and shape each other through an emergent iterative process. The comparative method and the iterative process allow the researcher to interact with the data and emerging analyses by asking analytical questions throughout the process, leading researchers to elevate their analyses to more abstract levels and intensify their power¹⁴14 Charmaz, K. Grounded Theory Methods in Social Justice Research. In: Denzin N, Lincoln Y, editors. The Sage Handbook of Qualitative Research. 4th ed. Thousand Oaks: SAGE Publications Inc.; 2011. p. 359-380..

The techniques employed in this research were the semi-structured interview and focus group. From a constructivist perspective, Guber considers that the interview “is a social relationship in such a way that the data provided by the respondent are the reality that he/she constructs with the respondent in the meeting¹⁵15 Guber R. La entrevista etnográfica o el arte de la “no directividad”. In: Guber R. La etnografía: método, campo y reflexividad. Bogotá: Norma; 2001. p. 75-100.”. On the other hand, the group technique allows the expression of beliefs and attitudes underlying or at the base of behavior. The data regarding perceptions and opinions are enriched/qualified through group interaction since individual participation can be enhanced or improved in a given group¹⁶16 Krueger R. Focus Groups: A practical guide for applied research. Newbury Park: Sage; 1988.^,1717 Morse MJ. Critical Issues in Qualitative Research Methods. London: Sage; 1994..

The analysis was guided by the coding and categorization process, consisting of three iterative moments: open coding, axial coding, and selective coding¹³13 Charmaz K. Shifting the Grounds. Constructivist Grounded Theory Methods. In: Corbin J, Clarke A, Charmaz K, Stern P, Bowers B, Morse JM, editors. Developing Grounded Theory The Second Generation. California: Left Coast Press; 2009. p. 127-147.^,1818 Strauss A, Corbin J. Codificación abierta. In: Strauss A, Corbin J. Bases de la investigación cualitativa Técnicas y procedimientos para desarrollar la teoría fundamentada. Medelín: Universidad de Antioquia; 2002. p. 110-133.. The Ethics Committee of the National School of Public Health of the University of Antioquia approved the study.

The topics that guided the interviews were the participants’ daily activities, how people feel and experience their assigned program, and the program’s opportunities to household members. The categories that guided the collection of the information were refined with the analysis and theoretical sampling, and the interview guide was progressively adjusted in this process.

The participants were: a) beneficiary mothers of the PPANs of Medellín and the Municipality of Angostura, Antioquia, Colombia, whose children had belonged, for at least two years, to one of the PPANs of their locations and, b) professionals with at least five years of experience working as technical operators, coordinators, or designers of any PPAN, at the local, departmental and national levels. Chart 1 describes the PPANs to which the study participants belonged. The first contacts with the beneficiaries and the interviewed technicians were facilitated by the fact that the researchers knew them previously. The other participants were selected using the snowball technique. All the participants were informed in detail about the study’s objectives and characteristics and signed the informed consent form. All the interviews were recorded and later transcribed verbatim. Chart 2 and Table 1 show the participants’ sociodemographic characteristics by type of interview (I: individual; G: group interview, initially planned as an individual but which in practice was developed with several participants and; FG: focus group).

The work of collecting, analyzing, and interpreting the information was carried out in two phases. The first phase consisted of conducting 12 interviews; 10 were aimed at beneficiary mothers and the other two at PPAN coordinators. The microanalysis of each transcribed interview was started as the information collection progressed. We performed an open coding, which resulted in 1,276 codes organized in an Excel file and classified by subject.

Fifty-four memos were built during the process, which were essential clues for the second phase of fieldwork and the formulation of some preliminary assumptions. Categories were built from the grouping of codes accounting for occurrences, events, and actions, similar or related by meaning, so that the categories corresponded to analytical ideas that represented the phenomena emerging from the data¹³13 Charmaz K. Shifting the Grounds. Constructivist Grounded Theory Methods. In: Corbin J, Clarke A, Charmaz K, Stern P, Bowers B, Morse JM, editors. Developing Grounded Theory The Second Generation. California: Left Coast Press; 2009. p. 127-147.^,1818 Strauss A, Corbin J. Codificación abierta. In: Strauss A, Corbin J. Bases de la investigación cualitativa Técnicas y procedimientos para desarrollar la teoría fundamentada. Medelín: Universidad de Antioquia; 2002. p. 110-133..

Some initial categories emerged as a result of this moment of analysis, and to reveal the relationships between the structure and the processes or, in other words, explain the actions and interactions of subjects in their daily lives with food and nutrition policies, a scheme called “paradigmatic matrix” was built, a tool proposed by the GT. An example of a paradigmatic matrix based on an emerging phenomenon resulting from the analysis process is shown in Figure 1. The second moment of the analysis consisted of the refinement of the paradigmatic matrices through data analytical reading and rereading. The analysis process achieved so far has guided, through theoretical sampling, the staging of 13 more interviews and a focus group. Seven of the interviews were directed to technicians who operated the policies and programs, and six to beneficiary mothers of three food and nutrition programs. Thirteen mothers participated in the focus group. This meeting aimed to provide feedback on the findings and to hear contributions from the participants. A total of 3,415 codes were obtained as a result of the microanalysis of this phase, which were close to the axial coding initially made. The constant comparison method progressed towards selective coding, from which the main category and the interrelated subcategories were retrieved, which are shown this work (Figure 2).

Results

The data analysis allowed us to understand that PPANs are conceived and managed under a market logic. This phenomenon is supported by three interrelated subcategories: a) institutional framework functional to the commercial model; b) outsourcing of all PPANs’ phases, and; c) operation focused on financial profitability (Figure 2).

Institutionality functional to the commercial model

The institutional framework was molded to the market scheme through a network of political, economic, and administrative conditions, which imposed a series of restrictions to implement the PPANs directly. The first is materialized in the Colombian legislation related to public contracting dating from 1993, which led institutions to resort to intermediaries’ figure by subcontracting mainly private institutions as policy or program operators.

Another element consisted of the fact that the country’s main PPANs were supervised by some international organizations (IO), which had an economic background because one of the policies with the highest coverage in the country was financed through credits from international banks. Another example is free trade agreements. Some technicians’ stories validated the idea of a rational individual who decides by maximizing his interests at the lowest price. From this perspective, the policy was seen as a mechanism to encourage consumer freedom. Food imports’ dependence was not a concern. Instead, the concern of not breaching trade agreements prevailed:

[...] shutting down imports would be like not having an adequate flow of food, and I know that the Government, that is, the President and other leaders, do not agree with these measures because they have already signed free trade agreements ... (DNP -D-23.9).

Disarticulation was another element that contributed to configuring a functional institutional framework for the commercial model, to the extent that each institution defined a population that was the object of the PPAN and outsourced third parties for its implementation. Thus, each sector carried out a series of specific actions independently without articulating efforts and resources from other institutions or programs.

Another cause for the disarticulation was targeting mechanisms, because each institution had its system for identifying its target population. As a result, several information systems fragmented the population in such a way that policies seldom converged in the same territory with a comprehensive offer to the communities.

Outsourcing in all phases of PPANs

Consistent with the above, the way to materialize the commercial logic of PPANs was through outsourcing, that is, the hiring of operators. With this mechanism, many of the State institutions were only responsible for auditing the operators’ actions. Under this logic, the State’s role in implementing the policy was limited to the performance of administrative processes and the supervision of contractors, which was at odds with the possibility of addressing the policy more comprehensively, rethinking the processes, and meeting the needs of the target population. The technicians felt frustrated when they experienced that their professional practice was primarily devoted to contracting and inspection tasks, to the detriment of their contribution to the communities from their field of expertise. One participant expressed this concern as follows:

[...] All that has been left aside because operations are always so complex; reviewing one by one, conditionalities. One is absorbed by operation, and the same happens to other social programs, and the same thing happens to all of us. (FA-D-21,18).

Another of the implications of outsourcing consisted of external operators arriving with their team of professionals at the locations, instead of hiring the human resources available in the territories. The programs were encouraged to privilege the food industry as their leading suppliers, to the detriment of the provision through the local market, or through the incentive to produce food in the territories. However, the main limitation of outsourcing was that under the country’s regulatory structure, policy actions had to be carried out precisely as established in the contract conditions. This situation left the State itself with a narrow maneuvering margin if it needed to redirect resources to assist the population in particular situations or crises. Likewise, these contracting mechanisms had little possibility of adapting to the particularities of communities with particular dynamics, such as those that depend on mining or ethnic minorities. In this way, a technician analyzed the implications of the most used contracting modality:

[...] The public tender is one that is most transparent to us, with the aggravating circumstance that you cannot change the tender: that’s the way it is! It does not allow you to adapt to what you find in the territory... You said that you were going to make a garden in an indigenous community with no water. Thus, the operator has to make a garden that will last a month because there is no water. The tender has that restriction. (DPS-D-22, 19).

It is important to note that some technicians and beneficiaries positively evaluated outsourcing third parties. The technicians said it allowed greater coverage since the State had a limited response capacity. Mothers highlighted positively receiving intervention from professionals from different fields, and they considered that the food nutritional, organoleptic, and safety characteristics were better. One beneficiary expressed her experience as follows:

[...] Thus, it is enjoyable because I learn too much. Furthermore, it is good because you correct yourself. It is pleasant because it helps you for the better. I believe that one’s life would be a little more disastrous without the Program. Of course, because they teach us: “you must do this, attempt to do this, try to do that (MA-M-11,13).

Operability focused on financial profitability

The figure for outsourcing led to the implementation of PPANs focused on the interest of economic profitability. An operator expressed it in the following way:

[...] I only have two percent profit left, and the program would have to give me ten percent (BC-PC-06, 11).

The thorniest issue derived from economic interest resides in the phenomenon of corruption. The most common figure that some operators resorted to was establishing organizations that specialized in obtaining contracts through public tenders, many of which did not comply with the contract specifications and, therefore, committed severe irregularities in the supply of the food subsidy. The technicians mentioned that these “front entities” were experts in evading judicial sanctions and had the savoir faire to continually apply to tenders because they resorted to specific strategies such as associating with others and frequently changing their business name. A technician recounted some of the mechanisms that operators adopted as follows:

[...] In many cases, operators have a company name in a particular place, but they create a temporary alliance, then they take another name. Furthermore, if they have impediments, they join with another person and change their name so as to not have a problem again in bidding in public tenders because they appear with another company name (DPS-D-22.25).

Discussion

The growing imposition of the market as the benchmark of the State. The foundations were laid for establishing the transnational capitalist class in the process of transformation of the Welfare State into the transnational State, with which a new social policy and economic globalization measures emerged. This neoliberal shift led globalization to be the benchmark, the new norm for the configuration and management of public policies, with the growing importance of the “market”⁵5 P. Tres retos para entender la acción pública hoy en día. In: Muller P. Las políticas públicas. 3ª ed. Bogotá: Universidad Externado de Colombia; 2010. p. 163-90.^,1919 Riojas-López C. 1989: Global History?. Iberoamericana [Internet] 2014; 14(54). [citado 2016 Oct 23]. Disponible en: http://journals.iai.spk-berlin.de/index.php/iberoamericana/article/view/134/762
http://journals.iai.spk-berlin.de/index.... . Such was the penetration of the neoliberal current that the decisions of the States and the transnationals are in practice almost identical²⁰20 Waitzkin H. El sentido común de la reforma a la salud. In: Waitzkin H. Medicina y salud pública al final del imperio. Bogotá: Universidad Nacional de Colombia; 2013. p. 197-208.. However, the transnational state requires the nation-state’s continuity, because this is where the decisions that materialize globalization take place and are legitimized²¹21 Abadía C, Oviedo D. Itinerarios burocráticos de la salud en Colombia: la burocracia neoliberal, su estado y la ciudadanía en salud. Revista Gerencia y Políticas de Salud 2010; 9(18):86-102.. The market context and, therefore, the neoliberal context, configured two phenomena that are intended to be discussed below: configure a State limited to overseeing actions and establishing public food and nutrition policies in devices for the diversion of public resources to the private sector.

Configuration of a State limited to action control. With the State reforms and the subsequent positioning of a market model that expands the participation of the private sector as an operator in the provision of social services, the main action of state institutions is limited to the control of operators, therefore, a “Check-list State” which has all its institutional resources to verify compliance with the activities carried out by contracted third parties emerges. This type of State is the result of the neoliberal economic model, which enacts its restricted participation in various dimensions, especially in public social policies, a phenomenon that other Latin American countries such as Brazil have experienced²²22 Cardoso A. Public Policy Agenda Setting: Fiscal Austerity in Brazil. Revista de Direito Setorial e Regulatório 2018; 4(1):111-130.^,2323 Machado ML, Garcia CG, Soar C, Mamed GR, Machado PMO, Lacerda JT, Martins MC, Marcon MC. Adequação normativa dos planos estaduais de segurança alimentar e nutricional no Brasil. Cad Saude Publica 2018; 34(1):1-14..

Contrary to the image that the neoliberal, minimal or streamlined State model has sold us, the check-list State is supported by a large bureaucratic apparatus that has gradually migrated its performance from the policy’s direct implementation to enforcement. The latter must not be homologated to a lesser need for human, logistical, and economic resources. On the contrary, it has seen the need to implement increasingly refined strategies to fulfill its oversight role, to the extent that outsourcing has become a financial fortress for the operators. Thus, this situation has exacerbated concern about the inadequate management of public resources, which can be read between the lines of the accounts of the beneficiaries and technicians interviewed for this research.

Institutionality uses the device of fragmenting and compartmentalizing the social issue. Consequently, it specializes in converting complex phenomena into a package of actions, thus translating the food issue into tendering language, which is the transaction mechanism between the State and third parties. This largely explains the disarticulation between the institutions, which the study’s participants of this study as one of the main stumbling blocks of PPANs, from which situations such as overlapping actions and over-intervention to beneficiaries. Disarticulation was seen as the root of inefficient policies. However, this study allows us to understand that it is an inherent condition for the commercial model’s deployment. Some authors also report this situation in Mexico and Chile. In the first case, it is argued that the disarticulation of the public food policy produces duplicated programs, poorly conceived strategies, and wasted resources²⁴24 López R, Gallardo E. Las políticas alimentarias de México: un análisis de su marco regulatorio. Estudios Socio-Jurídicos 2015; 17(1):11-39.. Salinas and Vio²⁵25 Salinas J, Vio F. Programas de salud y nutrición sin política de estado: el caso de la promoción de salud escolar en Chile. Rev chil nutr 2011; 38(2):100-116. warn about the disarticulation between the Ministries of Health and Education of Chile for implementing the School Health Promotion Policy, despite the various political agreements between both sectors to carry out joint work. The Chilean authors conclude that there is a gap between the diagnosis of the child and youth population’s health situation and the programmatic offer’s response to give an adequate response to said problem²⁵25 Salinas J, Vio F. Programas de salud y nutrición sin política de estado: el caso de la promoción de salud escolar en Chile. Rev chil nutr 2011; 38(2):100-116..

In this panorama, the question arises as to how the role of the State in rethinking comprehensive and universal policies, with which the welfare trend that translates into the delivery of a subsidy to meet minimum calorie and nutrient needs is overcome, loses ground as state institutions turn towards oversight. Likewise, there is concern about the loss of a State that focuses on oversight, rather than guaranteeing social rights. This mutation suffered by the State’s functions allows deducing that government institutions are more interested in their permanence than in providing care for their target population. Therefore, institutions’ vertical and disjointed configuration is expressed in their inability and indifference to address the social events affecting households comprehensively.

Diversion of public resources to the private sector through the PPAN device. The first element to explain the mechanism of diverting public resources to the private sector through public food and nutrition policies lies in the rearrangement of public and private boundaries. The State hands over the implementation of a significant segment of its social responsibilities to the private sector to the extent that the new benchmark imposes an interest in strengthening private companies⁵5 P. Tres retos para entender la acción pública hoy en día. In: Muller P. Las políticas públicas. 3ª ed. Bogotá: Universidad Externado de Colombia; 2010. p. 163-90.^,66 Sousa GW. Como reinventar a gestão e o funcionamento dos sistemas públicos e organizações estatais? Cien Saude Colet 2008; 13(Supl. 2):2019-2021..

The second element is the interference of the International Organizations -IO- in the public sector’s decisions. The IOs have played a decisive role in the design of public policies because many of them have made the fight against poverty one of their primary purposes and, consequently, as Pérez argues, have mobilized significant resources to carry out research that provides knowledge and statistics around the development/underdevelopment dialectic²⁶26 Pérez E. Los senderos de los Organismos Internacionales en la cooperación para el desarrollo: un panorama general sobre la evolución de las estrategias del Banco Mundial. Análisis Político 2016; 29(88):105-125.. Entities such as the World Bank -WB-, the World Trade Organization, and the International Monetary Fund, played a decisive role in the new configuration of public health policies²⁰20 Waitzkin H. El sentido común de la reforma a la salud. In: Waitzkin H. Medicina y salud pública al final del imperio. Bogotá: Universidad Nacional de Colombia; 2013. p. 197-208. and, therefore, in food and nutrition policies, not only in Latin America but also in most of the so-called low-income countries, as was the case of Bangladesh, where the World Bank becomes the administrator of the funds donated by different international entities for the operation of the National Nutrition Service Plan that mainly aims to improve early childhood feeding²⁷27 Rasheed S, Roy S, Das S, Chowdhury S, Iqbal M, Akter S, Jahan K, Uddin S, Thow AM. Policy content and stakeholder network analysis for infant and young child feeding in Bangladesh. BMC Public Health 2017; 17(2):27-38.. The WB promoted the recipe for the restructuring of the health sector in the so-called developing countries, with a substantial impact on the strengthening of the private sector, an aspect that was reflected in the emblematic 1993 report “Investing in Health”²⁸28 Banco Mundial (BM). Informe sobre el Desarrollo Mundial. Invertir en salud (Resumen) [Internet]. Washington: BM; 1993. [citado 2016 Oct 23]. Disponible en: http://documents.worldbank.org/curated/en/259121468340250256/pdf/341290spanish.pdf
http://documents.worldbank.org/curated/e... . Another strategy used by the IOs to divert public to private resources has been through free trade agreements, which have played a decisive role in shaping food and nutrition policies in the country. Illustrating this fact is the case of the growing corn imports from the U.S. by Colombia²⁹29 Dirección Nacional de Estadística (DANE). Balanza comercial [Internet]. Comercio exterior. 2016. [citado 2016 Nov 26]. Disponible en: http://www.dane.gov.co/index.php/comercio-exterior/balanza-comercial.
http://www.dane.gov.co/index.php/comerci... , although this food is one of the autochthonous and constitutive products of the food culture, and that the country has the conditions to achieve the production to supply the entire population. IOs’ interference has also promoted some hidden modalities of diverting public resources to the private sector, such as promoting conditional cash transfer programs -PTCE- in Latin America and through the leading role of food multinationals.

It is no coincidence that the expansion of the PTCEs started in the 1990s when neoliberal measures were most widely deployed. In 1997, only three countries implemented PTCEs. In 2010, they were present in 18 countries³⁰30 Cecchini S, Madariaga A. Programas de tranferencias condicionadas: balance de experiencias recientes en América Latina y el Caribe Santiago de Chile. Santiago: CEPAL; 2011.. In most countries, the PTCEs rely on the IOs, as is the case in Colombia, where 54% of the economic subsidy provided to families through the Families in Action Program came from loans made to the World Bank and the Inter-American Development Bank³¹31 Acción Social, DNP. El camino recorrido 10 años Familias en Accion. [Internet]. 2010. [citado 2016 Nov 26]. Disponible en: www.dnp.gov.co
www.dnp.gov.co... . Food multinationals also became recipients of public resources, to the extent that a significant number of PPANs incorporated processed foods produced by multinationals, which are delivered to beneficiaries as part of the subsidies.

The third noteworthy element is the proliferation of intermediaries, mainly private ones, to implement public policy actions. The precepts implanted by the neoliberal model consisted in that to increase efficiency: a) financing should be separated from service provision, b) it was necessary to promote competition between organizations, institutions, and the public and private sectors, c) the private administration was more efficient and less corrupt than the public one, and d) it should be aimed at subsidizing demand and not supply²⁰20 Waitzkin H. El sentido común de la reforma a la salud. In: Waitzkin H. Medicina y salud pública al final del imperio. Bogotá: Universidad Nacional de Colombia; 2013. p. 197-208.. From this perspective, the operators would become an extension of the State and implement a diversity of actions and strategies such as PPANs; likewise, a comprehensive menu of entities with interference in the entire spectrum of policies would proliferate, from their design, including their implementation and evaluation. Several authors analyze how non-governmental entities play an active role in implementing social policies, particularly those of health and nutrition, not only in Latin America but also in other continents such as Africa and Asia³²32 Hofisi M. State-NGO Relations in Africa. Mediterranean Journal of Social Sciences 2013; 4(10):291-298.

33 Galway L, Corbett K, Zeng L. Where are the NGOs and why? The distribution of health and development NGOs in Bolivia. Globalization and Health 2012; 8(32):1-13.

34 Aldashev G, Navarra C. Development NGOS: basic facts. Annals of Public and Cooperative Economics 2018; 89(1):125-156.

35 Song Y, Fu L. Do Charitable Foundations Spend Money Where People Need It Most? A Spatial Analysis of China. Int J Geo-Inf 2018; 7(3):1-17.^-3636 Werker E, Ahmed F. What Do Nongovernmental Organizations Do? Journal of Economic Perspectives 2008; 22(2):73-92.. During the development period of this research, some complaints about severe irregularities in child care by private operators were made, which showed that said entities had found a source of enrichment in the programs’ operation while not complying with the function for which they were recruited. The main concern was that political corruption networks were being set up to achieve social legitimacy because, while seeking their permanence, these structures resort to strategies such as meeting specific high-performance government objectives, so that some “benevolent corruption” associated with the social conditions of the country configures a scenario of poverty traps, since these corruption networks have greater agency capacity in marginal territories³⁷37 Gómez D. Redes de corrupción política: una revisión para el caso colombiano. Análisis Político 2018; 31(92):180-201.. Some reports show that 3,966 cases related to various forms of corruption³⁷37 Gómez D. Redes de corrupción política: una revisión para el caso colombiano. Análisis Político 2018; 31(92):180-201. were registered in the accusatory oral criminal system during the 2009-2016 period. Likewise, an official report revealed that ten so-called “business food networks” were in place in the country. They consisted of consortiums and temporary unions, made up of non-profit entities and profit-making companies, which moved the non-negligible sum of US$ 132 million (according to the November 2016 exchange rate) for the operation of food programs³⁸38 Auditoría General de la Nación. Mallas de la alimentación [Internet]. Bogotá, Colombia; 2016. [citado 2016 Nov 26]. Disponible en: http://www.auditoria.gov.co/Analisis_Contratacion/MALLAS%20EMPRESARIALES/Mallas_Alimentacion_Escolar.pdf
http://www.auditoria.gov.co/Analisis_Con... .

Conclusions

The market is imposed as the benchmark for the State’s actions and, therefore, loses ground as a guarantor of social rights to become a “Check-list State”. The institutional framework materializes the commercial rationale through outsourcing processes, covering all phases of food and nutrition policies. Finally, policies become devices for the diversion of public resources to the private sector.

Acknowledgments

The authors are grateful to the National School of Public Health of the University of Antioquia and the Health Policy and Management Research Group for the support and funding provided to develop the research in question.

References

Publication Dates

History