Abstract:

The Less Salt, More Life program was the first voluntary salt reduction initiative in Argentina. This article analyzes the perspectives of the stakeholders involved in this voluntary agreement between the Ministry of Health and the food industry to gradually reduce sodium content in processed foods. This exploratory case study used a qualitative approach including 29 in-depth interviews with stakeholders from the public and private sectors and identified the role of the different stakeholders and their perceptions regarding the challenges encountered in the policy process that contribute to the debate on public-private partnerships in health policies. The article also discusses the initiative’s main challenges and controversies.

Keywords:
Dietary Sodium Chloride; Nutrition Policy; Health Policy

Introduction

Hypertension is a major cause of cardiovascular disease, including stroke and coronary heart disease ¹1. Frisoli TM, Schmieder RE, Grodzicki T, Messerli FH. Salt and hypertension: is salt dietary reduction worth the effort? Am J Med 2012; 125:433-9.^,22. He F, MacGregor G. A comprehensive review on salt and health and current experience of worldwide salt reduction programmes. J Hum Hypertens 2008; 23:363-84.. Evidence shows that high dietary salt intake is a major risk factor for hypertension with a direct and progressive relationship between salt intake and hypertension ¹1. Frisoli TM, Schmieder RE, Grodzicki T, Messerli FH. Salt and hypertension: is salt dietary reduction worth the effort? Am J Med 2012; 125:433-9.^,33. He F, MacGregor G. Effect of modest salt reduction on blood pressure: a meta-analysis of randomized trials. Implications for public health. J Hum Hypertens 2002; 16:761-70.. It has also been estimated that reducing daily salt consumption from 10g to 6g reduces blood pressure and prevents coronary heart disease ²2. He F, MacGregor G. A comprehensive review on salt and health and current experience of worldwide salt reduction programmes. J Hum Hypertens 2008; 23:363-84.^,33. He F, MacGregor G. Effect of modest salt reduction on blood pressure: a meta-analysis of randomized trials. Implications for public health. J Hum Hypertens 2002; 16:761-70.. The World Health Organization (WHO) has set a target of less than 5g of salt per day per person, which equates to less than 2,000mg of sodium per day by 2020 ⁴4. World Health Organization. Diet, nutrition and the prevention of chronic disease. Geneva: World Health Organization; 2003. (WHO Technical Report Series, 916)..

However, consumption of salt is high worldwide ⁵5. Anderson CA, Appel LJ, Okuda N, Brown IJ, Chan Q, Zhao L, et al. Dietary sources of sodium in China, Japan, the United Kingdom, and the United States, women and men aged 40 to 59 years: the INTERMAP study. J Am Diet Assoc 2010; 110:736-45.. Studies in the Americas have also shown excessive salt consumption: Brazil 11g salt/day ⁶6. Sarno F, Claro RM, Levy RB, Bandoni DH, Ferreira SRG, Monteiro CA. Estimativa de consumo de sódio pela população brasileira, 2002-2003. Rev Saúde Pública 2009; 43:219-25., Chile 9.8g salt/day ⁷7. Ministerio de Salud. Encuesta Nacional de Salud? ENS Chile 2009-2010. http://www.minsal.cl/portal/docs/page/minsalcl/g_home/submenu_portada_2011/ens2010.pdf (accessed on 20/Jun/2016).
http://www.minsal.cl/portal/docs/page/mi... , United States 8.7g salt/day ⁸8. Henney JE, Taylor CL, Boon CS. Strategies to reduce sodium intake in the United States. Washington DC: The National Academies Press; 2010., and Canada 7.7g salt/day ⁹9. Nutrition Evaluation Division, Minsitry of Health. Sodium reduction strategy for Canada: recommendations of the Sodium Working Group. Ottawa: Ministry of Health; 2010.. In many countries, excessive salt intake is mainly caused by highly salted processed foods ²2. He F, MacGregor G. A comprehensive review on salt and health and current experience of worldwide salt reduction programmes. J Hum Hypertens 2008; 23:363-84.^,1010. Campbell N, Lackland D, Chockalingam A, Lisheng L, Schiffrin EL, Harrap S, et al. The World Hypertension League and International Society of Hypertension call on governments, nongovernmental organizations, and the food industry to work to reduce dietary sodium. J Clin Hypertens (Greenwich) 2014; 16:99-100.. Several studies conducted elsewhere have shown that approximately 80% of excess salt intake comes from salt added in the manufacturing processes of foods and not from salt added by the consumer when cooking ¹¹11. Havas S, Roccella EJ, Lenfant C. Reducing the public health burden from elevated blood pressure levels in the United States by lowering intake of dietary sodium. Am J Public Health 2004; 94:19-22.^,1212. Mattes RD, Donnelly D. Relative contributions of dietary sodium sources. J Am Coll Nutr 1991; 10:383-93.^,1313. Campbell NR, Correa-Rotter R, Legowski B, Legetic B. Iniciativas para reducir la sal alimentaria en la región de las Américas. Rev Panam Salud Pública 2012; 32:253-57.. Unlike countries where most salt intake comes from non-processed foods ¹⁴14. Souza ADM, Souza BDS, Bezerra IN, Sichieri R.The impact of the reduction of sodium content in processed foods in salt intake in Brazil. Cadernos de Saúde Pública 2016; 32:e00064615.^,1515. Gaitán D, Chamorro R, Cediel G, Lozano G, Silva Gomes F. Sodio y enfermedad cardiovascular: contexto en Latinoamérica. Arch Latinoam Nutr 2015; 65:206-15., in these countries where most of the salt intake comes from processed foods, reformulation policies have been estimated to have a major health benefit at the population level and have also shown to be a cost-saving intervention ¹1. Frisoli TM, Schmieder RE, Grodzicki T, Messerli FH. Salt and hypertension: is salt dietary reduction worth the effort? Am J Med 2012; 125:433-9.^,44. World Health Organization. Diet, nutrition and the prevention of chronic disease. Geneva: World Health Organization; 2003. (WHO Technical Report Series, 916).^,1616. World Health Organization. Salt reduction. Geneva: World Health Organization; 2014. (Fact Sheet, 393).^,1717. Asaria P, Chisholm D, Mathers C, Ezzati M, Beaglehole R. Chronic disease prevention: health effects and financial costs of strategies to reduce salt intake and control tobacco use. Lancet 2007; 370:2044-53.^,1818. Cobiac LJ, Vos T, Veerman JL. Cost-effectiveness of interventions to reduce dietary salt intake. Heart 2010; 96:1920-5.. In this article, the terms salt and sodium are used interchangeably.

In Argentina, hypertension is one of the main risk factors for cardiovascular disease ¹⁹19. Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJ. Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data. Lancet 2006; 367:1747-57.. Moreover, in 2005, high blood pressure accounted for 37% of all cardiovascular disease and strokes ²⁰20. Rubinstein A, Colantonio L, Bardach A, Caporale J, Martí SG, Kopitowski K, et al. Estimation of the burden of cardiovascular disease attributable to modifiable risk factors and cost-effectiveness analysis of preventative interventions to reduce this burden in Argentina. BMC Public Health 2010; 10:627.. Salt consumption is about 12g/day ⁴4. World Health Organization. Diet, nutrition and the prevention of chronic disease. Geneva: World Health Organization; 2003. (WHO Technical Report Series, 916).^,2121. Ferrante D, Konfino J, Mejía R, Coxson P, Moran A, Goldman L, et al. Relación costo-utilidad de la disminución del consumo de sal y su efecto en la incidencia de enfermedades cardiovasculares en Argentina. Rev Panam Salud Pública 2012; 32:274-80.. Estimates by the Ministry of Health indicate that more tha 60% of dietary sodium intake comes from processed foods ²²22. Ministerio de Salud. Iniciativa "Menos SAL, Más VIDA". http://www.msal.gob.ar/ent/images/stories/ciudadanos/pdf/2013-09_presentacion-acerca-reduccion-sodio.pdf (accessed on 20/Jun/2016).
http://www.msal.gob.ar/ent/images/storie... and that a reduction in total salt intake of 3g could prevent about 6,000 coronary deaths in the Argentinean population (40,000,000 inhabitants) ²¹21. Ferrante D, Konfino J, Mejía R, Coxson P, Moran A, Goldman L, et al. Relación costo-utilidad de la disminución del consumo de sal y su efecto en la incidencia de enfermedades cardiovasculares en Argentina. Rev Panam Salud Pública 2012; 32:274-80.^,2323. Ministerio de Salud. Boletín de Vigilancia de Enfermedades no Transmisibles y Factores de Riesgo 2010; n. 2..

Several countries have begun to implement sodium reduction strategies ²⁴24. Brinsden HC, He FJ, Jenner KH, Macgregor GA. Surveys of the salt content in UK bread: progress made and further reductions possible. BMJ Open 2013; 3:e002936.^,2525. McLaren L. Policy options for reducing dietary sodium intake in the School of Public Policy. Calgary: University of Calgary; 2013.^,2626. Webster JL, Dunford EK, Hawkes C, Neal BC. Salt reduction initiatives around the world. J Hypertens 2011; 29:1043-50.^,2727. Trieu K, McLean R, Johnson C, Santos JA, Angell B, Arcand J, et al. The science of salt: a regularly updated systematic review of the implementation of salt reduction interventions (June-October 2015). J Clin Hypertens (Greenwich) 2016; 18:487-94.^,2828. Trieu K, Neal B, Hawkes C, Dunford E, Campbell N, Rodríguez-Fernández R, et al. Salt reduction initiatives around the world-A systematic review of progress towards the global target. PLoS One 2015; 10:e0130247.. In 2009, the Ministry of Health launched the Less Salt, More Life Program with the aim of reducing salt consumption in the general population. The program first included an agreement with the Bakery Association to reduce sodium levels in bakery breads. In 2011, the Ministry of Health signed a voluntary agreement with the food industry to gradually reduce sodium content in four food groups: meat and meat products; bread and snacks; dairy products, with a focus on cheese; and soups, dressings, and canned foods. The following targets were set: for meat products, reductions from 5% to 15% per 100g. In the rest of the food groups there was a minimum 5% reduction based on a specific threshold, e.g. in the case of crackers, a minimum of 5% reduction has been set for products exceeding 600mg/100g ²⁹29. Ministerio de Salud. Tabla de alimentos procesados seleccionados en los que se realizará una reducción voluntaria y progresiva del contenido de sodio. http://www.msal.gov.ar/ent/images/stories/ciudadanos/pdf/2012-07_tabla-alimentos-seleccionados-reducira-sodio.pdf (accessed on Jul/2013).
http://www.msal.gov.ar/ent/images/storie... . This program did not set an expected sodium consumption target at the population level. In Argentina, the voluntary agreement was an initial step, followed by a national law. Two years after initiating the voluntary agreement, Argentina passed a sodium reduction law (Act. 26,905) which entered into force in December 2014 ³⁰30. Ministerio de Justicia y Derechos Humanos. Ley n. 26.905. Regulamenta la promoción de la reducción del consumo de sodio en la población. http://servicios.infoleg.mecon.gov.ar/infolegInternet/anexos/220000-224999/223771/norma.htm (accessed on Jul/2013).
http://servicios.infoleg.mecon.gov.ar/in... .

Voluntary agreements such as public-private partnerships (PPPs) assume cooperation between the public and private sectors, who agree to work together to achieve a common goal ³¹31. Kernaghan K. Partnership and public administration: conceptual and practical considerations. Canadian Public Administration 1993; 36:57-76.. The benefits and challenges of using a public-private partnership to address health issues have been analyzed in various studies ³²32. Kraak VI, Harrigan PB, Lawrence M, Harrison PJ, Jackson MA, Swinburn B. Balancing the benefits and risks of public-private partnerships to address the global double burden of malnutrition. Public Health Nutr 2012; 15:503-17.^,3333. Petticrew M, Eastmure E, Mays N, Knai C, Durand MA, Nolte E. The Public Health Responsibility Deal: how should such a complex public health policy be evaluated? J Public Health 2013; 35:495-501.^,3434. Richter J. Public-private partnerships for health: a trend with no alternatives? Development 2004; 47:43-8.^,3535. Bryden A, Petticrew M, Mays N, Eastmure E, Knai C. Voluntary agreements between government and business: a scoping review of the literature with specific reference to the Public Health Responsibility Deal. Health Policy 2013; 110:186-97.. This qualitative study design aims to contribute to the body of literature and research into decisions in the public health sector regarding voluntary initiatives and PPPs in the prevention of non-communicable diseases, attempting to understand the policy process of PPPs from the stakeholders’ perspectives. The specific objectives included: (1) to identify the role and resources of the different major stakeholders; (2) to analyze the main challenges and controversies perceived by stakeholders; and (3) to analyze the stakeholders’ perspectives concerning mandatory vs. voluntary initiatives.

This study is part of a comprehensive quantitative and qualitative research strategy to monitor sodium reduction policies in Argentina ³⁶36. Allemandi L, Tiscornia MV, Ponce M, Castronuovo L, Dunford E, Schoj V. Sodium content in processed foods in Argentina: compliance with the national law. Cardiovasc Diagn Ther 2015; 5:197-206..

Materials and methods

We used qualitative techniques to analyze the perspectives of the major stakeholders in the policy-making context ³⁷37. Varvasovszky Z. Alcohol policy in Hungary [Doctoral Dissertation]. London: School of Hygiene and Tropical Medicine, University of London; 1998. (Table 1). Stakeholder analysis is widely recommended as a tool for gathering insights on stakeholder interests in, positions on, and power to influence health policy issues ³⁷37. Varvasovszky Z. Alcohol policy in Hungary [Doctoral Dissertation]. London: School of Hygiene and Tropical Medicine, University of London; 1998.^,3838. Varvasovszky Z, Brugha R. A stakeholder analysis. Health Policy Plan 2000; 15:338-45..

This study includes documentary policy analysis and semi-structured interviews. National policy documents were retrieved from official government webpages. Interviews were conducted between October 2012 and March 2013. Interviewees were purposely selected according to their level of involvement in the policy process. Participants included government officials participating in the Less Salt, More Life Program and representatives of food associations and companies that had signed the voluntary agreement. We also used a snowball strategy to complete the sample. In total, 29 informants were interviewed including: (a) two experts on the technical and political aspects of sodium reduction; (b) 11 decision-makers from Ministries and government agencies (three from the Ministry of Health, three from the National Institute of Food Products, one from the Ministry of Agriculture, four from the National Institute of Industrial Technology); (c) 11 food companies; and (d) five food industry associations. Most of the private sector interviews (10) were conducted with product reformulation experts. In the case of food associations, the presidents were interviewed in every case. With regards to policymakers, we interviewed civil servants (four) and food experts (seven) from different departments and agencies.

All the major food associations and food companies were included in the final sample. Stakeholders were contacted by e-mail and/or by telephone (at least three e-mails were sent). Only one of the selected stakeholders explicitly refused to participate in the study. It was not possible to obtain responses from some companies, mainly small companies located outside the province of Buenos Aires. Interview topics were developed based on a review of the literature ³⁷37. Varvasovszky Z. Alcohol policy in Hungary [Doctoral Dissertation]. London: School of Hygiene and Tropical Medicine, University of London; 1998.^,3939. Hyder A, Syed S, Puvanachandra P, Bloom G, Sundaram S, Mahmood S, et al. Stakeholder analysis for health research: case studies from low- and middle-income countries. Public Health 2010; 124:159-66. and adapted to the research. The interview guides included questions on the following topics:

Interviews were open-ended, with probes to explore points raised by interviewees, or for clarification if more information was required. Interviews lasted about one hour, were carried out in Spanish by two members of the research team, in most cases at the interviewee’s workplace, and were then recorded and transcribed verbatim. All interviews took place in a safe environment. Before discussing the questions, all participants provided verbal consent. The research protocol was approved by the Hospital CEMIC’s Committee on Ethics in Research Protocols

All transcripts were read and re-read several times to gain thorough familiarity with the responses. The Atlas.ti 7.0 software (Muhr T. Scientific software development GmbH, Berlin, Germany) was used to manage the process of coding and categorizing data. The codes from the different transcripts were reviewed while maintaining the principle of constant comparison analysis ⁴⁰40. Thorne S. Data analysis in qualitative research. Evid Based Nurs 2000; 3:68-70. (Table 2).

Triangulation of researchers with different backgrounds and knowledge of the sector was very important to test initial coding and combine different perspectives. Quotes are presented throughout the results section to contribute to the trustworthiness of the research.

Results

Roles and resources of participating stakeholders

The National Sodium Reduction Commission was created in early 2010. The creation of this Commission was identified as the actual starting point for the program, which included stakeholders from the public sector, private sector, and civil society organizations (Table 3).

The Ministry of Health was the initiative’s main driving force.

Level of knowledge and awareness of the subject varied according to the stakeholder and sector.

The Ministry of Health was responsible for recruiting other participants and for planning, organizing, and coordinating the meetings of the National Sodium Reduction Commission. Within this Ministry, the main areas included the Program on Chronic Non-Communicable Diseases and the Health Surveillance Office.

The Ministry of Agriculture collaborated with the Ministry of Health and led the Communication Commission whose main responsibilities were focused on communication activities targeted both to the food industry and the general population (source: interviews).

The National Institute for Food Products (INAL in Spanish), an agency of the National Administration of Medicines, Food, and Medical Technology (ANMAT in Spanish) led the design and implementation of the monitoring strategy. ANMAT is an independent body within the Ministry of Health.

The National Institute of Industrial Technology (INTI in Spanish), an independent public agency, also participated in this initiative. Three different sectors within the INTI (dairy, meat, and grain and oilseeds) provided technical assistance to small and medium enterprises to set baseline sodium levels and reduction targets. Although the grain and oilseeds sector had an initial technical advisory role at the beginning of the process, it later withdrew from the program (source: interviews).

The Ministry of Social Development, the National Health Quality Service (SENASA in Spanish) and the Science and Technology Department, although formally part of the voluntary agreement, did not participate actively in the program (source: interviews and Ministry of Health official presentations).

Within the private sector, food associations and food companies were invited to participate by the Ministry of Health. Data from Euromonitor 2012 showed that companies with the largest market share in Argentina participated in the program ⁴¹41. Euromonitor International. Packaged food in Argentina. London: Euromonitor International; 2012.. The Ministry of Health and Ministry of Agriculture signed agreements with the Association of Food Industries (COPAL) to reduce sodium content in their product portfolio. These agreements clearly specified the reduction levels each product should reach. Individual agreements were also signed with each participating company (source: interviews and Ministry of Health official presentations). Although participation in the program was voluntary, upon signing the agreement companies agreed to meet their commitment to conduct gradual and progressive reductions in the products covered by the agreement.

In case of noncompliance, the Ministry of Health could issue a written notification in order to demand regularization. No penalties were specifically mentioned in the agreements.

Only larger companies and food associations participated actively in the commission. Likewise, larger companies were already aware of the importance of sodium reduction in their products and had knowledge on international trends and regulations. Many companies had already implemented sodium reduction strategies even before the Ministry of Health initiative. Many had even achieved the initial reduction targets. Companies that had already made sodium reductions in their products committed to continue implementing gradual and progressive reductions over time (source: interviews).

Product and brand selection varied according to the company involved. While some companies prioritized products with higher sodium levels, others selected highly consumed products, and still others selected products in which sodium was already being reduced. Companies were responsible for defining baseline sodium levels. Interviews showed that public sector stakeholders viewed the food industry as having the most technical expertise, especially to set reduction targets and with a crucial role not only in setting targets but also in selecting products for inclusion in the voluntary agreement.

“We’re always calling on experts from the scientific community, because they [companies] know much more than we do about ‘cookie X’, and that will always be the case. That’s their business” (interview, Ministry of Health).

“Negotiations begin with discussions about which reductions can be made, and accordingly, about where reductions may not be possible. That’s how the percentage reductions were set” (interview, Private Sector).

The Ministry of Health communicated with civil society and non-governmental organizations, including scientific societies, academia, and consumers’ organizations, who were invited to participate in the program. However, these organizations were not identified as having an active role in designing, implementing, and monitoring the policy. These organizations were mainly invited to be informed about the salt reduction efforts and to assist the Ministry of Health in raising awareness and disseminating information to the general population (source: interviews).

Challenges and controversies

Technological assistance to small and medium-size companies

Some participating companies expressed a need for special assistance to meet the targets set by the Ministry of Health. The interviewees felt there were a significant number of small and medium-size enterprises with limited technical and economic resources to implement technological innovations. The lack of economic and human resources and innovation departments made it more difficult for these companies to reduce sodium content in their product portfolio. These companies stated that they lacked accurate data on sodium levels in their products. The interviewees reported that for these companies, the importance of the public sector’s role in providing technological assistance was widely acknowledged.

“In small and medium companies, the issue of technological development is complicated. (…) We were telling government to look for an incentive mechanism so that the companies could make these changes. It could be financial help or technical support. Some companies don´t make the changes because they don’t know” (interview, Private Sector).

Differences in economic resources between large and small and medium-size enterprises should also be considered when assessing the level of influence of the different stakeholders. The public sector did not provide financial support or special funds for technological research. Companies were responsible for potential expenses related to product reformulation.

“We tell them [the private sector] what to do and monitor them, but they have to invest the money. They’re the ones who have to reformulate their products (….)” (interview, Ministry of Health).

Monitoring sodium reductions

Most stakeholders working on food safety issues had not included the importance of sodium reduction in their agendas until they were contacted by the Ministry of Health. They saw sodium reduction as a new and useful initiative to raise awareness among other public stakeholders.

“… within the official network of laboratories, the first priority is to detect food pathogens, then contaminating agents. (…) Sodium was not an issue for us before. (…) Now it has become a public health problem, as or more important than bacteria. So we have started to focus on the needs and priorities and on investment issues regarding the analysis of sodium content in industrialized foods” (interview, Public Sector).

The INAL, in charge of monitoring the policy, was equipped with the necessary technology in its laboratories to perform chemical analyses. Monitoring sodium reduction required several technical specifications. On July 15, 2016, the Ministry of Health published the results of the first official monitoring analysis, showing that most of the foods surveyed complied with the current sodium reduction targets ⁴²42. Ministerio de Salud. Salud evaluó el cumplimiento de la reducción de sodio en los alimentos procesados. http://www.msal.gob.ar/prensa/index.php?option=com_content&view=article&id=3188:salud-evaluo-el-cumplimiento-de-la-reduccion-de-sodio-en-los-alimentos-procesados&catid=6:destacados-slide3188 (accessed on 20/Jul/2016).
http://www.msal.gob.ar/prensa/index.php?... .

Besides the official monitoring process, food companies have also been required to submit periodic reports to the Ministry of Health, informing on progress with the reductions.

More challenging targets

Sodium reduction entails a variety of difficulties because of the different functions sodium has in processed foods, especially flavor and preservation. According to the stakeholders, the targets were not identified as raising significant technological changes. However, interviews showed that further targets would require new technological developments, including more research on salt substitutes.

“Reduction targets are reasonable and do not require big innovations or developments. You clearly need to make adaptations. But for the time being, in this initial stage, the Ministry of Health intends to continue reducing sodium in the same products [processed/ultra-processed products included in the agreement]. But if you have to continue reducing sodium, then you’ll need to find substitutes” (interview, Private Sector).

Some industry representatives highlighted the importance of evaluating sodium substitutes. According to these interviewees, such substitutes should be evaluated and approved by the national body in charge of food regulation and should also be included in the Argentinean Codex Alimentarius. They also highlighted the different functions that salt has in meat products, not only for preservation and taste but also for the product’s organoleptic properties. The private sector felt that “they [government] have to help us with new additives” (interview, Private Sector).

Cheese products also employ a different process for adding salt when compared to other food groups. With the negotiated targets, the food industry reported having reached the maximum possible reduction. Larges companies in the industry agreed that “we are already at the limit of consumer acceptance [the lowest acceptable amount of sodium], considering the product’s acceptance and technological feasibility” (interview, Private Sector).

Awareness-raising campaigns

All stakeholders cited awareness-raising campaigns as an essential part of the initiative. Although some isolated media activities had already taken place, various stakeholders reported difficulties in designing a communication strategy to address the general population.

“We still haven’t defined the communication strategy for certain health warnings: the risks of excessive salt intake, for example. Those issues are not so easy to communicate. Some people get scared; others don’t want to hear about it, while others feel reluctant… You can’t just tell them that ‘salt kills you’, you simply can’t…” (interview Ministry of Agriculture).

Private sector participation

Within the wide range of public and private sector organizations, most interviewees felt that inter-sector dialogue was one of the initiative’s most important strengths. However, opposing views were also identified, especially related to the way the policy was developed. Some stakeholders expressed concern about the private sector’s role in certain stages of the policy process, such as selecting food groups and setting reduction targets.

“I think […] that companies were able to choose [what products to include in the Agreement]. I think that [….] you can’t let them choose” (interview, INTI).

Public sector representatives agreed that the policy should not be used for marketing purposes. Therefore, the Ministry of Health did not allow the use of a logo on food packages that would give consumers the idea that the companies belonged to the program.

“We didn’t allow [logos], because they would add a confounding factor to the products’ labeling. Because even if a snack has a x% reduction in its total sodium content, sodium would still be high in that product” (interview, Ministry of Health).

Mandatory versus voluntary initiatives: stakeholders’ perspectives

For both public and private sector stakeholders, the voluntary agreement’s importance was based on the possibility of future regulation. Two years after implementation of the voluntary agreement, Argentina passed a sodium reduction law (Act. 26,905) which entered into force in December 2014. The law includes maximum levels similar to the values set in the voluntary agreement in three main food groups ³⁰30. Ministerio de Justicia y Derechos Humanos. Ley n. 26.905. Regulamenta la promoción de la reducción del consumo de sodio en la población. http://servicios.infoleg.mecon.gov.ar/infolegInternet/anexos/220000-224999/223771/norma.htm (accessed on Jul/2013).
http://servicios.infoleg.mecon.gov.ar/in... . Even if the law had not been enacted when this study was being done, the possibility of a regulation had been foreseen by various stakeholders.

For the public sector, implementation of this voluntary initiative was acknowledged as a first step before introducing a regulation.

“Once we finish the work involved in the voluntary agreement, when we have clearer targets and know how many companies are able to comply with the agreement without making modifications, then I think it will be the time to introduce regulation (…) when you introduce a regulation but you can’t include at least 80 percent of the market, such a regulation will be ineffective” (interview, Ministry of Health).

Likewise, one of the reasons the food industry agreed to participate in the program was the idea of being able to “anticipate” regulation. The voluntary agreement was seen an arena for industries to estimate potential sodium reductions and prepare for future negotiations with the public sector.

“…when we decided to join this voluntary agreement, we wanted to have time to work inside our company and become sensitive to this health issue. Only then would it be time to consider legislation” (interview, Private Sector).

Many companies saw the agreement as a first and necessary step towards legislation.

“If legislation had been compulsory [before the industry became involved in the voluntary agreement], the entire food industry would have reacted, and the legislation might have been ‘turned down’, to use a term” (interview, Private Sector).

Discussion

This was the first qualitative study to analyze and discuss the different perspectives of the main stakeholders in the policy process of a voluntary agreement on sodium reduction.

Based on the interviews, we found that both the public and private sectors viewed partnership between the Ministry of Health and the food industry as an essential component throughout the process. One aspect most valued by interviewees was inter-sector collaboration. From their perspective, such collaboration helped to put salt reduction on the public agenda and to promote the current national sodium reduction legislation. However, the analysis of the Argentinean case also showed important challenges for this type of voluntary initiative.

Although the Less Salt, More Life Program was clearly initiated by the Ministry of Health, the food industry, mainly led by big companies, played a leading role in the policy process. First, the interviews showed that companies selected the products for inclusion in the program and established the reduction targets without a clear statement from the public health authorities on how much reduction was needed in each food category in order to produce the estimated benefits (⁴³.

In other countries ⁴⁴44. Charlton K, Webster J, Kowal P. To legislate or not to legislate? A comparison of the UK and South African approaches to the development and implementation of salt reduction programs. Nutrients 2014; 6:3672-95.^,4545. Webster J, Trieu K, Dunford E, Hawkes C. Target salt 2025: a global overview of national programs to encourage the food industry to reduce salt in foods. Nutrients 2014; 6:3274-87., targets have been based on solid research evidence, and a sodium model was used to calculate how much salt would have to be removed from each food category in order to reduce the sodium content in the food supply by 40% ⁴⁴44. Charlton K, Webster J, Kowal P. To legislate or not to legislate? A comparison of the UK and South African approaches to the development and implementation of salt reduction programs. Nutrients 2014; 6:3672-95.. Likewise, in order to have a substantive impact on salt intake it is necessary to combine weighted sales averages and upper limits in designing the targets ¹⁰10. Campbell N, Lackland D, Chockalingam A, Lisheng L, Schiffrin EL, Harrap S, et al. The World Hypertension League and International Society of Hypertension call on governments, nongovernmental organizations, and the food industry to work to reduce dietary sodium. J Clin Hypertens (Greenwich) 2014; 16:99-100..

Second, industry representatives stated that the maximum levels set by the voluntary agreement would not require any technological changes, but this would not be true in the case of further reductions. The quantitative analysis conducted in Argentina has documented a wide range of sodium levels within the same food groups and categories, which illustrates the feasibility of further reductions in the country ³⁶36. Allemandi L, Tiscornia MV, Ponce M, Castronuovo L, Dunford E, Schoj V. Sodium content in processed foods in Argentina: compliance with the national law. Cardiovasc Diagn Ther 2015; 5:197-206..

It remains to be seen how future reductions will demand technological adaptations and whether the private sector will ensure the technical capability to meet such challenges. This is an important challenge for the future, since reductions have been foreseen as gradual. It is important for the public and private sectors to discuss the feasibility of further reductions based on updated evidence. Thus, capacity-building by different civil society stakeholders will be essential, particularly universities and research centers free of conflicts of interest, in order to conduct reliable and independent research on the feasibility of further sodium reductions and assist small and medium-size companies. The latter have apparently been at a disadvantage and have expressed the need for technical support to ensure a level playing field.

Third, the private sector’s argument that it has “already reached the limit of consumer acceptance” should be thoroughly examined, based on evidence that consumers do not notice gradual salt reductions in food ⁴⁶46. Stuckler D, Nestle M, Big food, food systems, and global health. PLoS Med 2012; 9:e1001242. and that repeated step-wise reductions in salt alter the palate’s salt-sensitivity (making salty food less pleasant to the taste over time) ⁴⁷47. Levings JL, Cogswell ME, Gunn JP. Are reductions in population sodium intake achievable? Nutrients 2014; 6:4354-61.. Further research is needed to fully understand the impact of gradual reductions in sodium content on consumers’ taste and acceptance over time ⁴⁸48. Bobowski N. Shifting human salty taste preference: potential opportunities and challenges in reducing dietary salt intake of Americans. Chemosens Percept 2015; 8:112-6.^,4949. Lewin A, Lindstrom L, Nestle M. Food industry promises to address childhood obesity: preliminary evaluation. J Public Health Policy 2006; 27:327-48..

Between 2010 and 2014, the number countries reporting some form of national salt reduction initiative more than doubled, from 32 to 75. However, only South Africa and Argentina have adopted comprehensive legislation to limit salt levels in foods ²⁷27. Trieu K, McLean R, Johnson C, Santos JA, Angell B, Arcand J, et al. The science of salt: a regularly updated systematic review of the implementation of salt reduction interventions (June-October 2015). J Clin Hypertens (Greenwich) 2016; 18:487-94.^,2626. Webster JL, Dunford EK, Hawkes C, Neal BC. Salt reduction initiatives around the world. J Hypertens 2011; 29:1043-50.. The new sodium reduction law enacted in December 2013 made Argentina the first country in the Americas to move from a voluntary initiative to legal regulation.

The shift was largely due to health authorities’ interest in this public health issue and its priority on the public agenda, resulting in rapid progress for Argentina, but also because the targets had already been negotiated with the private sector. The law includes the reduction of sodium content in a list of processed foods, among other measures targeting restaurants and public awareness campaigns. The voluntary initiative analyzed in this study laid the foundations for enacting the subsequent law. Our results highlight the importance of the food industry’s role throughout the process. The impact of this role is another essential aspect for an objective evaluation of the regulation’s effectiveness in the future. As mentioned elsewhere ⁴⁶46. Stuckler D, Nestle M, Big food, food systems, and global health. PLoS Med 2012; 9:e1001242.^,4949. Lewin A, Lindstrom L, Nestle M. Food industry promises to address childhood obesity: preliminary evaluation. J Public Health Policy 2006; 27:327-48.^,5050. Magnusson RS. Non-communicable diseases and global health governance: enhancing global processes to improve health development. Global Health 2007; 3:2.^,5151. Marks JH, Thompson DB. Shifting the focus: conflict of interest and the food industry. Am J Bioeth 2011; 11:44-6.^,5252. Moodie R, Stuckler D, Monteiro C, Sheron N, Neal B, Thamarangsi T, et al. Profits and pandemics: prevention of harmful effects of tobacco, alcohol, and ultra-processed food and drink industries. Lancet 2013; 381:670-9.^,5353. Nestle M. Food politics: how the food industry influences nutrition and health. Berkeley: University of California Press; 2002. industry’s role in formulating policies on non-communicable diseases remains controversial because of its potential conflicts of interest.

A major critique of voluntary initiatives is that industry’s interests override health interests by setting the agenda for compliance ³⁵35. Bryden A, Petticrew M, Mays N, Eastmure E, Knai C. Voluntary agreements between government and business: a scoping review of the literature with specific reference to the Public Health Responsibility Deal. Health Policy 2013; 110:186-97.. As shown in reformulation policies, large food corporations control both the development and reformulation of processed foods ⁵³53. Nestle M. Food politics: how the food industry influences nutrition and health. Berkeley: University of California Press; 2002.. The analysis of Argentina’s voluntary agreement revealed the complexities involved and the lack of an important counterweight to the food industry when defining technical issues. Likewise, the effectiveness of public-private partnerships varies between countries ¹⁷17. Asaria P, Chisholm D, Mathers C, Ezzati M, Beaglehole R. Chronic disease prevention: health effects and financial costs of strategies to reduce salt intake and control tobacco use. Lancet 2007; 370:2044-53.. In this context, the public health community should carefully analyze the implications of PPPs, not only because of their voluntary nature, but also because public health policies should remain independent of any form of influence.

Governments should thus promote comprehensive public policies that positively impact the population’s health. Reformulation policies should be complemented by other measures such as public awareness campaigns, economic incentives to increase consumption of fruits and vegetables, and policies to discourage consumption of ultra-processed foods.

The study’s strength is its analysis of the stakeholders’ perspectives in this voluntary initiative. The analysis highlights the importance of certain stakeholders and interest groups in the policymaking process and the challenges of PPPs. However, the study is subject to a number of limitations. Observations were made across a period of time and the policy environment, while stakeholders’ influences and positions are subject to change.

Another limitation of this study is that no in-depth interviews were planned and conducted with civil society representatives to obtain have a detailed analysis of this sector’s participation. However, a previous study conducted with civil society organizations in the region has shown that most organizations in Argentina are in their initial stages in sodium reduction strategies (⁵⁴. Also, interviews were conducted months before the enactment of the new national law, making it difficult to capture trends in the discussion and how issues such as implementation, monitoring, and impact were addressed.

Conclusions

Stakeholders interviewed in this study showed unequivocal support for this voluntary sodium reduction initiative. However, some expressed concern over the food industry’s role in different parts of the policy process, such as setting reduction targets.

Although salt reduction policies have made significant progress in Argentina, from a voluntary initiative to legal regulation, further research is needed to estimate the impact of these measures on actual salt intake and the population’s health, together with clear and transparent monitoring of the new law. Technical assistance should also be provided to small and medium companies. The implementation of a target-based approach to gradual salt reduction for the entire processed food supply will be critical in the future. In addition, more active participation by civil society organizations will further contribute to the policy’s success.

Acknowledgments

The authors wish to thank the participants from both the public and private sectors for making this study possible. This research was supported by the International Development Research Centre (IDRC), Canada.

References

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