Governmental institutionalization of corporate influence on national nutrition policy and health: a case study of Ecuador

Summary

Corporate influence in policy and decision-making is an important public health concern. This Health Policy paper reviews Ecuador’s child malnutrition strategy instruments, approved between 2020 and 2023, to identify how private interests are becoming legally integrated into the public sector. Evidence indicates that recent changes are enabling corporations to promote their brands, gain tax deductions, oversee public policy and set priorities, allocate resources, and decide on implementation of the country’s child malnutrition strategy. Further, corporate representatives are active members of an advisory council, free from scrutiny or accountability, while being privy to undisclosed government information. Moreover, a UN agency (the World Food Program) engaged in corporate promotion of highly processed foods, illustrating the breadth of Ecuador’s corporate influence scheme. Improved regulations should set clear limits to the influence of food and beverage industries in national nutrition policy, while following transparency laws in the composition and operation of Ecuador’s child malnutrition strategy and related efforts.

Introduction

Chronic child malnutrition is a persistent public health issue around the world.¹ Multiple factors, including poverty, and inadequate access to healthcare, education, and nutritious food, contribute to the problem.² Moreover, many low- and middle-income countries suffer from the double burden of malnutrition (the concurrent manifestation of undernutrition and overweight/obesity). In Ecuador, 23% of children under 5 years of age and 27% under 2 years of age have chronic malnutrition,³ while 64.7% of the population aged 18–69 is overweight and obese.⁴ Diet-related non-communicable diseases such as hypertension and diabetes are prevalent in 9.3% and 6.6% of the population 18–69, respectively.⁴

Different social, political, and economic forces shape dietary practices. Increasingly, the commercial determinants of health (CDOH) are recognized as a powerful and distinct set of drivers of population health.⁵ Gilmore et al.⁶ define the CDOH as the systems, practices, and pathways through which commercial actors (e.g., financial sector, food industry) drive health and social inequities both within and between countries. There is a large body of evidence about the deleterious effects of sweetened beverages and ultra-processed foods on human health (particularly among children).⁷ Nevertheless, food industries (those producing and selling ultra-processed food and beverage products) continue to thrive and grow, particularly in emerging economies.^8,9 Similar to other countries in Latin America, Ecuador’s market deregulation has been linked to increases in sales per capita of ultra-processed foods and beverages by a highly concentrated oligopoly.¹⁰ In this context, public health efforts must carefully consider the role of private commercial entities in shaping the public’s health.

The ultra-processed food industry practices in South America share characteristics with the “new responsibility deal” approach in the United Kingdom,¹¹ such as the creation of commercial entities¹² to operate on the behalf of for-profit companies. In Brazil, for instance, the food industry has responded to concerns with the commercial determinants of health by creating entities to lobby with the Legislature and expand their corporate influence.¹³ In Colombia, the food industry created a common front, the National Industry Association (Asociación Nacional de Industriales, in Spanish), working together with lobbying firms, guilds and companies.¹⁴ In Chile, industry actors engaged in corporate political activity directly (including by members of government with conflicts of interest) and indirectly (through the revolving door).¹⁵

In 2013, all 194 World Health Organization (WHO) Member States endorsed 19 policies to address key non-communicable disease (NCD) risk factors, 12 of which are aimed at the commercial determinants of health.¹⁶ WHO and other partners such as the Food and Agriculture Organization (FAO) and the World Bank have recommended that governments adopt a series of measures, such as increasing taxes on ultra-processed foods and beverages to curb the rise of NCDs,17, 18, 19 and Ecuador had taken important steps in this direction. In 2016, Ecuador introduced a tax on sugar-sweetened beverages, shortly after implementing traffic light food labeling.²⁰ However, the country has not since adopted other recommended policies, such as curtailing the marketing of ultra-processed foods and beverages. Recent government decisions suggest that private interests are being prioritized above the public’s health in Ecuador. An independent assessment gave the country a 42% implementation policy score and ranked it 85 (out of 194) in the Corporate Financial Influence Index,²¹ which measures a country’s ability to prevent undue financial influence on policymaking.

Policy implementation to address NCDs has not progressed as needed around the world.²² One of the strategies has been the implementation of public-private partnerships towards addressing malnutrition,²³ broadening the range of commercial entities influencing policy and decision making.¹² In many instances, transparency (essential to both accountability and the identification of potential conflicts of interest) seems lacking.^12,24 Given the research gap in the relationships between private interest and public health and nutrition policy,²⁴ it becomes crucial that the structures and mechanisms of influence by ultra-processed food industries are more transparent.²⁵

The purpose of the present Health Policy paper is to review Ecuador’s chronic child malnutrition strategy instruments, approved between 2020 and 2023, to identify mechanisms of governmental institutionalization of undue corporate influence by the ultra-processed food and beverage industries. To collect relevant legal and policy documents and public records on food and beverages industries and related commercial entities, we monitored policies issued by the government, requested information from government offices, and conducted searches in government databases and Google, to gather publicly available information on participating companies and organizations. Amounts are expressed in US dollars (US$), which is the currency used in Ecuador.

Industry influence on public health policy

Ultra-processed food industries commonly engage in corporate practices to influence or drive national policy in their favor^26,27 through a range of strategies. They include shaping of narratives and creation of counter-narratives,²⁸ engaging professionals and community actors to promote their brand and products,²⁹ lobbying, or making direct campaign contributions to politicians. For instance, Nestlé, a transnational food conglomerate, recently donated US$2.2 million to the World Health Organization Foundation (although the money was redirected to a different organization only after public outcry).³⁰

Revolving door practices—whereby executives rotate between government and industry jobs—are not unusual.³¹ Even in high-income countries, there are few obstacles to repeatedly cross these boundaries–often at a senior level–between the public and private sectors, many of them acting with clear conflicts of interest.^32,33 Closely related, lobbying and revolving door politics are likely a form of political corruption³⁴ and should be cause for concern. Bennett et al. (2023) have called for the monitoring of corporate practices of unhealthy commodity industries based on surveillance indicators that allow the identification of drivers of commercial influence on health.²⁷

Involvement of industry in public health policy in Ecuador

Like other countries in the region, Ecuador suffers from entrenched corruption and institutional weakness.^24,35 As an example, one of the largest international private-political corruption schemes in the region also took place in the country.^24,36 It involved the Odebrecht construction industry conglomerate, which operated for three decades engaging in bribes connected to the highest levels of many Latin American governments.²⁴ Correspondingly, studies have shown limited transparency of decision and policy making in Ecuador.^37,38 A recent study of the prices of medical supplies in government purchases pointed towards the need for greater scrutiny and transparency specifically in the health sector.³⁹ Similarly, another study found limited transparency in the discussions and resolutions of the emergency operations committee during the COVID-19 pandemic.⁴⁰

In the past few years, the relationship between the private sector and the state seems to have grown closer. While the government's joint efforts with the private sector led to a relatively swift Covid-19 vaccination campaign,⁴¹ the private sector-led distribution of basic medicines within the public health care system has lacked transparency (e.g., regarding how much the government paid for Covid-19 vaccines).⁴² Similarly, “investor-friendly” legislation has given concessions and state-backed investments and incentives (including tax exemptions) to shrimp farms, disregarding the documented impact on environmental and human health and livelihoods.⁴³

During the Rafael Correa administration (2007–2017), the National Coordinator of Feed Ecuador (Aliméntate Ecuador, in Spanish, a supplemental food program for children under 5 years of age, senior citizens, and people with disabilities), influenced a bidding process to benefit the director’s daughter and son-in-law’s company -which became the main provider of granola bars for the government’s school food program and was paid US$30 million in a single year.⁴⁴ From a public health perspective, the sale of granola bars unnecessarily introduced an ultra-processed food into the diet of Ecuadorian children and adolescents. Coincidentally, the same person is a long-standing executive officer of Asociación Vivir, which in turn, is one of the member organizations of the Ecuador Free of Child Malnutrition Secretariat (Secretaría Técnica Ecuador Crece Sin Desnutrición Infantil, STECSDI), a potential conflict of interest that has not been declared as such in the documents we examined.

Evolution of Ecuador’s child malnutrition strategy since 2020

Beginning in 2020, an Executive Order by President Lenin Moreno created the National Strategy called Ecuador Grows Without Malnutrition.⁴⁵ The Order assigned the responsibility of monitoring and making recommendations on implementation and decision-making to the autonomous Life Course Plan Secretariat. The subsequent administration of President Guillermo Lasso changed the name of the Life Course Plan Secretariat to Ecuador Free of Child Malnutrition Secretariat (STECSDI)⁴⁶ in July of 2021. That same year, a former top executive at a large pharmaceutical company, without any background in public health or nutrition, became an Ad Honorem government “advisor on public policy for the fight against child malnutrition”³ and president of the first STECSDI Advisory Council.³ The same person led the drafting of the Intersectoral Plan to Prevent and Reduce Chronic Child Malnutrition,³ which was launched in September, 2021.

That same year, the non-profit Ecuadorian Child Nutrition Network (Red Ecuatoriana de Nutrición Infantil, REDNI) was founded by representatives from the National Association of Food and Beverages Makers (Asociación Nacional de Fabricantes de Alimentos y Bebidas, ANFAB), which groups 83 global corporations including Bimbo, Mondelez, Coca Cola, Pepsico, Quala, Kellogg’s, Abbott, Nestle, Omnilife, Griffith Foods and Ferrero.⁴⁷ A series of additional legal decisions finalized the structure supporting the involvement of global food and beverage corporations and commercial entities related to them in Ecuadorian policymaking (Fig. 1; see Supplementary Table S1 for the list of companies involved).

Fig. 1.

Chronology of the most recent legal decisions increasingly supporting the involvement of food and beverage industry corporations in Ecuadorian policymaking. REDNI, Red de Nutrición Infantil (Child Nutrition Network).

From December 30, 2021 to January 23, 2023, four crucial regulations were approved in Ecuador:

• •December 30, 2021. Executive Order 304 creates the tax deduction mechanism for companies sponsoring non-profits purportedly focusing on the eradication of chronic malnutrition and on pregnant mothers.⁴⁸
• •September 13, 2022. Inter-institutional agreement MIES-MSP-MINEDUC-MAATE-STECSDI-2022-001 establishes how programs/projects in chronic child malnutrition may qualify for tax deductions.⁴⁹
• •October 4, 2022. Secretariat Agreement STECSDI-2022-0003-A tasks an Advisory Council with overseeing and promoting public policy with the aim of formulating a Chronic Child Malnutrition Law.⁵⁰
• •January 23, 2023. Executive Order 645 reduces taxes on alcoholic and sugar-sweetened beverages (and tobacco).⁵¹

Separately, these orders or agreements may not raise concerns at first sight. Taken together, however, they create a legal structure for undue commercial influence on health that does not appear to have a precedent in other countries in the region. First, the mandate creating the Advisory Council of the Ecuador Free of Child Malnutrition Secretariat allows it to be judge and jury of the national chronic child malnutrition strategy, by tasking it with: 1) observing and advising the strategy and related instruments, and 2) guiding the implementation and assessment of the strategy, including through promoting participation and channeling civil society participation.⁵⁰

Second, different stipulations allow the Advisory Council members to conduct themselves with hardly any constraints, free from scrutiny and accountability mechanisms that otherwise apply to public servants. Because the council is not government funded,⁵⁰ its members are not required to declare their assets, nor are they legally bound to submit any reports during their tenure. Also, the Executive Orders do not require representatives to declare all the companies and organizations they have connections with, to examine any potential conflicts of interest (something other people serving in government positions are required by law to do). Finally, it can be assumed that the expenditures and salary costs are covered by their companies and organizations. Therefore, these amounts can be counted as tax deductible (as per scheme established via Executive Order 304).

The powers bestowed unto the Advisory Council are critical. Its members include representatives from the United Nations (UN) agency World Food Program, Inter-American Development Bank, European Union, higher education institutions (Universidad San Francisco de Quito, Escuela Politécnica del Litoral, Instituto Argos), an international non-governmental organization (NGO) (Plan International), Ecuadorian NGOs (Youtopía, Justicia y Paz, Asociación Vivir, Fundación Kisht and Fundación Esquel), a network of NGOs (Pacto por la Niñez y la Adolescencia), and civil society organizations (Asociación de Montubios, Mesa San Lorenzo), a professional association (Association of Nutritionists) and the for-profit sector (El Ordeño, National Association of Food and Beverages Makers, ANFAB, and Child Nutrition Network, REDNI). Fig. 2 shows the relationships and direction of influence from ultra-processed food companies, through their non-profit organizations, to public institutions charged with implementing Ecuador's chronic child malnutrition strategy.

Fig. 2.

Relationships between ultra-processed food companies, public institutions, and non-profit organizations linked to Ecuador’s chronic child malnutrition strategy. Arrows indicate direction of influence. REDNI, Red de Nutrición Infantil (Child Nutrition Network); ANFAB, Asociación Nacional de Fabricantes de Alimentos y Bebidas (National Association of Food and Beverage Makers).

REDNI is an interesting entity. It was first registered on 14 December of 2021, two weeks before Executive Order 304 created the tax deduction mechanism. From their own website, it is evident that REDNI’s founders have strong corporate ties. The contributing partners of REDNI are major stakeholders in Ecuador’s food and beverages industry. Its two largest contributors, Corporación Favorita and Pronaca, are also ANFAB members (See full list of registered capital by contributing partner in Supplementary Table S2). Further, two members of the Advisory Council are employed as Executive Director and Manager of Political Articulation and Influence of REDNI.⁵²

In another example, Corporación Favorita (via its own non-profit Fundación Favorita, registered in June of 2021), partnered in early 2023 with the UN agency World Food Program to promote their own processed foods across their chain of supermarket stores.⁵³ Additionally, ultra-processed food industries organize outreach events, such as Corporación Favorita in partnership with World Vision, for pregnant women and mothers,⁵⁴ and Tonicorp (owned by Coca Cola), for families.⁵⁵ Finally, one of the Advisory Council members, Asociación Vivir (involved in the supplemental food program scheme mentioned above), conducts evaluation studies for REDNI.^56,57

Intertwining private interests in public health decision making

Public health research on the commercial determinants of health has only recently considered the broader range of commercial entities influencing policy and decision making.¹² During 2022, the Ecuador Grows Without Malnutrition National Strategy operated with a US$200 million loan from the Development Bank of Latin America (CAF),⁵⁸ distributed as follows: the Secretariat (US$10.62 million), Ministry of Public Health (US$75.58 million), Ministry of Economic and Social Inclusion (US$167.36 million). Although the program is not financed by donations from the private sector, the commercial entities represented in the Advisory Council have the power to guide how the budget is spent, while having firsthand access to privileged information that may inform their own tax-deductible initiatives. In other words, private sector members of the Advisory Council are in a unique position to benefit from efforts pursued under the umbrella of a public national strategy.

Further, achievement indicators of the Intersectoral Plan to Prevent and Reduce Chronic Child Malnutrition³ released by STECSDI do not allow the public to verify whether their actions are effectively transparent. For instance, for Strategic Action 1 “Implement an inter-institutional and intersectoral governance, monitoring and oversight system guaranteeing transparency,” the indicators are “Executive Decree” and “STECSDI’s organizational governance structure”, instead of actual implementation thresholds. Similarly, for Project/Action for improvement 6.2 “Promote citizen action among the most vulnerable and diverse populations” the indicator is “Number of social organizations that participate in the ECSDI strategy”, and not, for instance, an evaluation of whether the promotion of citizen action effectively took place. Finally, for Project/Action for Improvement 6.4 “Align the efforts of social responsibility of private business and civil society in general towards chronic child malnutrition issues” the indicator is “Number of public-private agreements”, instead of the actual alignment of actions that should be assessed.

Integration of private interests in the public sector

Our analysis was guided by the “potential surveillance indicators for corporate practices” framework proposed by Bennett et al. (2023) to identify how private interests may become legally integrated into the public sector. We find that, in Ecuador, the lines between the two sectors may have become blurred under the framework of the chronic child malnutrition strategy. Table 1 shows the six corporate practices intervening in Ecuador’s efforts to address chronic child malnutrition. We find evidence of direct participation in government agencies and partnerships (through the Advisory Council), revolving doors (two members of the advisory council are employed as REDNI’s Executive Director and Manager of Political Articulation and Influence), pressures on the national government (corporate entities represented in the Advisory Council include ANFAB, a conglomerate of 83 transnational corporations operating in Ecuador), pressures on international organizations (Corporación Favorita partnered in early 2023 with the Word Food Program to promote the purchase of processed foods in their supermarket chain), and preference shaping via corporate social responsibility schemes (Corporación Favorita organized outreach events with the international non-profit World Vision, geared towards pregnant women and mothers) and civil society capture (REDNI, working in partnership with the same corporate members of ANFAB).

Table 1.

Ultra-processed food and beverage industry’s influence in Ecuador’s chronic child malnutrition strategy.^a

Practice	Definition	Evidence
Political environment
Direct participation in government agencies, partnerships	Representatives of corporate entities on national policy committees/fora	•Members of the Advisory Council of the Ecuador Free of Child Malnutrition Secretariat who belong to the food and drink industry and their commercial entities have access to formal policy-making processes, including privileged information.
Revolving doors	Instances where high-level government officials are employed by corporations within 5 years of government employment and vice versa	•Two members of the Advisory Council of the Ecuador Free of Child Malnutrition Secretariat are employed as Executive Director and the Manager of Political Articulation and Influence of the Child Nutrition Ecuadorian Network (Red de nutrición Infantil, REDNI) •A former top executive at a large pharmaceutical company, without any background in public health or nutrition, became an Ad Honorem government advisor on public policy for the fight against child malnutrition and president of the first Advisory Council of the Ecuador Free of Child Malnutrition Secretariat between 2021 and 2022
Pressures on national governments	Market concentration of corporations in unhealthy commodity industries in the national economy	•Among the commercial entities represented in the Advisory Council are a milk company (El Ordeño) with a registered capital of USD 6.5 million, and the National Association of Food and Beverages Makers (ANFAB), which groups 83 transnational corporations.
Pressures on International Organisations	Financial support provided annual to key international organisations (e.g., WHO, WTO), absolute and relative to total	•Through its non-profit (Fundación Favorita) registered in June of 2021, Corporación Favorita partnered in early 2023 with the UN agency World Food Program to promote the purchase of processed foods in its own supermarket chain.
Preference shaping
Corporate social responsibility (CSR)	Events/campaigns aimed at promoting corporate social responsibility; Sponsorship money of sporting or cultural associations/clubs, events/donations/charity affiliations	•Outreach events organized by Corporación Favorita in partnership with World Vision, for pregnant women and mothers, and Tonicorp (owned by Coca Cola) for families.
Civil society capture	Front-groups identified as having connection to industry	•REDNI, a “civil society” initiative founded in late 2021, counts among its partners many of the same corporate members of ANFAB, including the largest processed food industries (e.g., Pronaca) and supermarket chains (e.g., Corporación Favorita)

^aIdentified using Bennet et al.’s indicators for potential surveillance of corporate practices.²⁶

Our analysis further demonstrates how policies and instruments were consecutively drafted without evidence of public or civil society oversight. The scheme began with including the possibility of deducting taxes from child malnutrition programs/projects. With the secretariat coopted by the ultra-processed food and beverage industry, the authority of public entities (e.g., Ministry of Public Health) was undermined. This scheme gave national and global food corporations the power to oversee public policy related to child malnutrition, and influence priority setting, resource allocation and implementation. Such a scheme allowed the food industry to gain both tax reductions and deductions, and even established their own “civil society” or “non-profit” entities eligible for such benefits (e.g., REDNI, which was founded at around the same time when the tax deduction policy was enacted).

We also find a lack of transparency or accountability mechanisms in this approach to address chronic child malnutrition. The somewhat novel (albeit legal) structure has offered companies that already have a strong grip on the ultra-processed food and beverage market, the means to lead the national chronic child malnutrition strategy (via the Advisory Council) and reduce their taxes. Even in Organization for Economic Co-operation and Development (OECD) countries, legislation has not prevented an increase in the presence of the revolving door, with a lack of effective monitoring and credible enforcement mechanisms to blame.⁵⁹ If the efforts of global corporations in low- and middle-income countries are left unchecked, a course correction that may contradict or challenge private sector interests seems almost impossible.

Nevertheless, Ecuador already has a framework to place limits on private interests in the banking and media sectors. To prevent conflicts of interest, the Constitution⁶⁰ forbids bank and media shareholders from owning stock in companies established in Ecuador that do not operate in the same line of business. Ecuadorian law also places strong limitations regarding information sharing by policy and control authorities, and revolving door use by bank and insurance executives, shareholders, and politicians.⁶¹ Furthermore, banks’ social responsibility initiatives (e.g., financial literacy workshops) may not be used to promote their brand, products, or services.⁵¹ Based on such legal precedents, it should be possible to introduce reforms targeted to curtailing corporate influence by the ultra-processed food industry in national nutrition policy.

Conclusion

The present study provides evidence that corporate influence (by ultra-processed food and beverage industry) in nutrition and health policy and health has been increasingly institutionalized over the past four years through different policy instruments under the umbrella Ecuador’s chronic child malnutrition strategy. The Ecuadorian government’s approach to tackling this public health issue suggests that public-private partnerships for health, if at all needed, must first be transparent about their structures, leadership, and funding mechanisms. Second, legal frameworks must include provisions for continuous accountability of partnerships to the public. Improved regulations should also include setting limits to the influence of ultra-processed food and beverage industries in nutrition and health policy, stipulating transparency mechanisms to reveal the composition of all advisory and operational non-commercial and commercial entities involved in the country’s chronic child malnutrition strategy and related efforts. All policy and programs, such as the Intersectoral Plan to Prevent and Reduce Chronic Child Malnutrition, should be revised to ensure achievement indicators allow transparent assessment of the national strategy and robust participation of civil society individuals and organizations.

Contributors

IT and JV conceptualised the manuscript. IT, JV and DLC collected and analysed the data. SG critically revised the manuscript at all stages. All authors contributed to drafting and editing the manuscript. IT was responsible for the decision to submit the manuscript.

Data sharing statement

Documents reviewed in this article are publicly available.

Declaration of interests

We declare no competing interests.