Enhancing nutrition specific interventions through public health policies and public-private partnerships in the Eastern Mediterranean Region: a desk review

Study design

The study design was descriptive using secondary data obtained from digital internet sources as the primary data collection method, i.e. a desk review.

Data collection

The data on the role/contribution of the private sector, and the challenges encountered in the implementation of specific nutrition interventions across EMR countries was collated through a comprehensive literature review from various sources, including WHO Global database on the implementation of nutrition actions (GINA), grey literature, specific reports on nutrition actions published by implementing partners (WHO, UNICEF, WFP, FAO) and other UN and International development agencies.

The first step of the data collection process aimed at developing a comprehensive list of specific nutrition policies/actions that have been implemented across EMR countries. A team of three reviewers conducted the database search using GINA database (A–Z country list) to develop a comprehensive list of specific nutrition actions for each of the 22 EMR countries. The countries were distributed among the reviewers as per the WHO classification for EMR countries (Table 1).

The information gathered from GINA, included name of country, name/title of the nutrition initiative, background information on the initiative, and the implementing partners.

The second step of the data collection process included a grey literature and Google web search for articles and reports published between 2010 and 2020 in English. The search also included websites of UN and international development agencies to locate detailed information on the actions that were not included in GINA or google search. For the Google search, reviewers used the following search terms “specific title/name of the nutrition program/ action with the country name”.

The reviewers used the inclusion criteria (defined below) to screen the full text independently and as a team of three to determine the eligibility of the nutrition action/ program.

The initial list was then narrowed down to include only specific nutrition actions/interventions that were implemented in partnership with at least one private for-profit organization.

A short data extraction table (Microsoft Excel 2013) was used to extract the information from the internet sources to allow for data analysis and documentation of findings. The main variables that were extracted from the literature included country name, name of the action/intervention, program objectives, implementing partners, role and responsibilities of the partners, reported challenges, and reported health outcomes/evaluation if available.

Inclusion criteria

In order to find and select the nutrition actions relevant to the objective of this study, the following inclusion criteria was developed to inform the data collection process:

Role of the private sector in promoting good nutritional practices in EMR countries

Following the WHO guidelines, all EMR countries have integrated the promotion of infant and young children feeding practices (IYCF) at the primary care level as part of the antenatal and postnatal packages of care. Initiatives for promoting exclusive breastfeeding and complementary feeding counseling for infants and young children were also provided during ante-natal and post-natal visits in most of the countries of the region. The implementation of these initiatives has required the involvement of many stakeholders including the Ministries of Health, international and UN development agencies as well as national NGOs. Other initiatives targeting IYCF in these countries included the implementation of the Baby-Friendly Hospitals) as part of the global efforts to protect and support breastfeeding.

The role of the private sector in the development and implementation of IYCF actions in advanced nutrition transition countries (ANT)¹ was only reported in Bahrain. The IYCF program in Bahrain was developed in collaboration with the International Baby Food Action Network (IBFAN), and the agencies for importing and distributing breast milk substitutes in the country¹⁶. In early nutrition transition countries (ENT)², private sector involvement was only reported in Lebanon. The Lebanese Ministry of Health worked in close collaboration with UN agencies (WHO, UNICEF), international NGOs, Order of Nurses, and the private media to promote exclusive breastfeeding¹⁷. In EMR countries with significant under-nutrition/in complex emergency (SUN/CE)³, the involvement of the private sector in the implementation of IYCF actions was reported only in Pakistan and Iraq. In 2019, the government of Pakistan launched a Breast-Feeding Campaign in collaboration with UNICEF, and the private sector¹⁸. Through this program, 50 million people were reached by disseminating IYCF messages through theaters, seminars, social media and television spots. The program was funded through corporate social responsibility. A similar breastfeeding promotion campaign was also implemented in Iraq in collaboration with UNICEF and in partnership with the national mobile network provider Zain¹⁹.

Following WHO guidelines, ANT and ENT countries have also enacted laws/regulations to protect and promote exclusive breastfeeding by implementing the International code for marketing of breast milk substitutes (the code)⁴. However, none of these countries have succeeded in achieving full implementation of the code regulations. The most common reported challenge in the implementation of the code included the governments’ inability to monitor and enforce the compliance of the relevant stakeholders, including the private sector. Lack of adequate monitoring and enforcement mechanisms of the code was also reported in Bahrain¹⁶, and the Kingdom of Saudi Arabia (KSA)²⁰. In Kuwait, over-prescription of infant formula by the private sector physicians has also been identified as one of the main challenges in implementing the code²¹. A weak monitoring and evaluation framework, accompanied by weak advocacy and implementation mechanisms of the code was also reported in Jordan²², and Lebanon. In Lebanon, some hospitals violated the code by providing pre-lacteal feeding before breastfeeding and offering samples for mothers upon discharge²³. The implementation of the code regulations is highly determined to the engagement and compliance of the private sector (food manufacturers and distributors). However, information on the role of the private sector in the implementation of the code was lacking.

Role of the private sector in the provision of micronutrients for children and mothers

Within EMR countries, programs to provide different micronutrients supplementation (vitamin D, iron, folic acid) to different age groups are mainly led by the government with no involvement from the private sector. Engagement of the private sector in the implementation of vitamin A supplementation programs in EMR countries was only reported in Palestine through government partnership with local producers of fortified biscuits and milk²⁴. In Somalia, the National Micronutrient Deficiency Control Strategy indicated the important role of the private pharmaceutical industry in supplying, promoting and implementing quality controls on the program²⁵. However, available evidence on the involvement of the private sector in this initiative was not available in the literature.

Role of the private sector in therapeutic feeding of malnourished children

In both ANT and ENT countries, protocols for screening and management of severe acute malnutrition (SAM) and moderate acute malnutrition (MAM) have been incorporated through food distribution programs and have been integrated at the primary health care level. Yet none of these initiatives has involved the private sector. In SUN/CE countries, the screening and management of SAM and MAM are being led by Ministries of Health in collaboration with UNICEF as the lead agency and other UN development agencies, including the WHO, WFP, and local NGOs on the ground.

The involvement of the private sector in SAM treatment was reported only in Sudan and Pakistan. In 2019, the Sudan Ministry of Health in partnership with UNICEF collaborated with local ready-to-use therapeutic food (RTUF) manufacturers to strengthen the supply chain of RTUF in three Darfur states and the states of South Kordofan and Khartoum²⁶. This partnership resulted in maintaining an adequate reserve of RTUF in the supply pipeline. In Pakistan, the WFP and UNICEF are working with local manufacturers to increase the local production of RTUF²⁷.

Role of private sector in food fortification initiatives

Salt iodization (SI) and wheat flour fortification (WFF) are the two most common food fortification initiatives in the region. According to the literature, the implementation of WFF programs in most of the EMR countries is being led by the Ministries of Health working in partnership with several UN development agencies, international development agencies, donors, and the private sector (mills industry). The same applies to SI initiatives. For the past two decades, WHO and UNICEF have been working in close collaboration with the International Council for Control of Iodine Deficiency Disorders (ICCIDDs), other international agencies and the salt industry to support the governments in the region in developing their national salt iodization programs. In 2008, UNICEF fostered a new partnership with the Global Alliance for Improved Nutrition (GAIN) to further support the SI programs in selected priority countries in urgent need for SI²⁸.

The majority of the ANT countries have achieved good coverage of WFF and have reported improvement in health outcomes as a result of the food fortification initiatives. Examples of successful food fortification initiatives include Kuwait, whereby one industrial mill in the country produces all of the flour, and 100% coverage of fortification is reported²⁹. In ENT countries, WFF is mandatory in the Islamic Republic of Iran, Jordan and Morocco. Other countries have introduced voluntary measures for flour fortification such as Lebanon. In Egypt, a flour fortification program (with iron and folic acid) has been stalled since the political changes in 2011, despite having undergone a 5-year preparatory phase²⁹. Examples of successful flour fortification initiatives include the ones implemented in the Islamic Republic of Iran and in Jordan, with fortification levels of 100% and 93%, respectively²⁹. The success of the Jordanian WFF program was attributed to the government strength in enforcing the food industry compliance with food regulations and standards³⁰. Other countries including Egypt and Lebanon are experiencing challenges in implementing and sustaining these initiatives. These challenges are the result of poor enforcement mechanisms and coordination by the governments, as well as limited resources²⁹.

In SUN/CE countries, WFF is mandatory in Djibouti, Iraq, Palestine, and Yemen. Most countries have introduced WFF voluntary legal standards, except for Libya and Somalia where flour fortification is not implemented yet²⁹. The Pakistan partnership with the private miller’s industry for the implementation of the national WFF program, did not yield the expected health benefits/desired national coverage³¹.

All ANT countries have also implemented SI initiatives on a national scale, except for the KSA. SI iodization programs in the United Arab Emirates (UAE) and Kuwait are progressing quickly toward achieving full coverage and eliminating iodine deficiency disorders in their countries³².

ENT countries have also implemented mandatory SI initiatives on a national scale. Some have policies guiding the process of salt iodization including Egypt, the Islamic Republic of Iran, Lebanon, and Morocco³². According to the literature, the partnership between the government and salt producers for the implementation of the national salt iodization program is both sustainable and effective. The SI in Jordan has significantly contributed to achieving better health outcomes by reducing iodine deficiency disorders in the country³³. In Lebanon, a policy brief to inform the national SI program was published through a joint effort of affiliated centers at the American University of Beirut (AUB), international NGOs and donors. The brief noted that, despite the existence of a law for SI, the lack of financial resources and poor enforcement mechanisms are hindering effective implementation³⁴. In Morocco, the government failed to sustain the SI initiative due to increased competition from non-iodized salt producers³². Other challenges imposed due to the activities of the private sector are notable in Egypt, where many salt producers, re-packagers, and unlicensed salt producers continue to threaten the sustainability of salt iodization due to the lack of effective governmental monitoring mechanisms³⁵.

In SUN/CE countries, SI initiatives are being implemented in Afghanistan, Iraq, Libya, Pakistan, Palestine, Sudan, Syria, and Yemen. According to UNICEF, Afghanistan is on track but still has a long way to go. Countries including Sudan, Pakistan Somalia and Yemen continue to struggle with attaining the minimal required consumption of iodized salt³⁶.

Based on the available literature, it was evident that the private sector plays a significant role in the implementation of food fortification initiatives (FFIs) in most of the EMR countries. However, it was also evident that many of the countries in the region are facing major challenges in the implementation of their FFIs due to the gaps in their regulatory framework, lack of financial resources, and weak monitoring and enforcement mechanisms.

Role of the private sector in nutrition actions targeting obesity

The literature showed that the private sector has a sizable role in the implementation of nutrition actions promoting healthy diets in both ANT and ENT countries. However, the information on the countries’ experience with PPPs in the domain of obesity prevention and control is not readily available.

At the policy level, some of the ANT and ENT countries such as Bahrain, Saudi Arabia, Kuwait, Oman, Egypt and Jordan have enacted reformulation policies/legislative measures to reduce salt and trans-fatty acids in food products³⁷. Others have taken nutrition actions to reduce sugar intake, such as Egypt, Jordan, Morocco, and Tunisia. Nutrition labeling legislation was also adopted in countries such as Bahrain, the UAE, Saudi Arabia, Tunisia and Jordan. In Bahrain and the UAE, labeling is mandatory and supported by the country’s national policy³⁸.

Marketing of unhealthy food for children is also being regulated in some of the EMR countries as well. Oman has established legislation to ban the marketing of unhealthy foods and beverages to school age children. Egypt, the Islamic Republic of Iran, Morocco, and Tunisia have introduced a taxation and price policy on unhealthy foods and/or beverages³⁸. Food guidelines and standards were also adopted in the Islamic Republic of Iran, Lebanon, and Morocco. According to best practices, the implementation of these policies requires the involvement of the private sector (food manufacturers). However, data on the role of the private sector in these initiatives was not available.

At the program level, the majority of ANT and ENT countries have developed multi-sectoral platforms for the prevention and control of non-communicable diseases. These actions involved different partners, including ministries of Health, Education and Sports, alongside different UN agencies, the WHO, national NGOs and the private sector (representatives from the food industry). Qatar has established a large scale multi-sectoral network, including the private sector, media, education, and research centers, as well as the tourism sector to support the implementation of its obesity nutrition actions. The Qatar experience illustrates the role of the tourism sector (hotels and restaurants) in increasing the reach of obesity awareness and the role of the private sector in mobilizing resources³⁸. A similar multi-sectoral program was also implemented in Oman to prohibit the marketing of high-fat, energy dense, and/or micronutrient-poor foods and beverages on school premises³⁸.

The involvement of the private sector in obesity interventions in both ANT and ENT countries is well reported through a variety of programs. Engagement of the media in the implementation of awareness campaigns on healthy eating practices was reported in Bahrain, Qatar, KSA, Lebanon, the Islamic Republic of Iran, Jordan, Morocco, and Tunisia. Similarly, the UAE has worked closely with the private sector to implement various obesity awareness initiatives, such as the UAE’s national program “2021 Healthy Children Initiative “and the “Health Heroes” smart app³⁹. Bahrain and Saudi Arabia were the only countries to implement awareness campaigns at the workplace to increase awareness about obesity and its related consequences.

Partnership with the food sector (local bakeries) to reduce the amount of salt added to bakery products was reported in Bahrain, Morocco, and Tunisia. Other examples of the food industry involvement include, the “United for Healthier Kids U4HK” initiative led by Nestlé Middle East and implemented in the UAE and Kuwait to help parents establish healthier eating, drinking and lifestyle habits for children aged four to 12³⁹. In Saudi Arabia, the “Al-Haraka Baraka physical activity promotional Initiative” is a collaborative effort between a public university (King Saud University), a non-profit organization (Arab Nutrition Center), and the private sector (Mars Middle East Inc.). This initiative is designed as an educational program targeting school aged children 6-12 years of age⁴⁰.

These findings indicate that EMR countries have taken major steps towards developing policies and implementing strategies to prevent and combat obesity in partnership with the private sector. However, more evaluation evidence is needed to determine the impact of these partnership on health outcomes.

Among SUN/CE, only Pakistan has taken some action to control the increased prevalence of obesity among adolescents and adults. In 2019, the Pakistan Ministry of Health developed a policy paper on adolescent (boys and girls) nutrition in Pakistan⁴¹. This project was done in partnership with the World Bank, GAIN, and Safansi. In 2020, the Ministry of Health in Pakistan took serious steps toward eliminating industrially produced trans fatty acids with the support of SUN Business Network (SBN), and GAIN, in partnership with the International Food and Beverage Alliance⁴². Both programs involve partnership between the government of Pakistan and the private sector. However, both projects are still in the initiation phase and thus evaluation data was not available.

Underlying data

Dryad: Public –Private Partnerships in Nutrition Specific Interventions in EMR Countries, https://doi.org/10.5061/dryad.dv41ns1ww⁴³.

Data are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).