Health Promotion International, Vol. 18, No. 1, 5-14,
March 2003
© Oxford University Press 2003
Holding fast: the experience of collaboration in a competitive environment
1Health Promotion Consultant, Christchurch and 2Department of Public Health and General Practice, Christchurch School of Medicine and Health Sciences, University of Otago, New Zealand
Address for correspondence: Heather Fear, Health Promotion Consultant, 24 Glendevere Terrace, Christchurch 8008, New Zealand, E-mail: rhfear{at}clear.net.nz
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SUMMARY |
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 TOP SUMMARY INTRODUCTIONTHE NATURE OF COLLABORATIONTHE NEW ZEALAND CONTEXTRESEARCH APPROACHTHE COLLABORATION EXPERIENCEDISCUSSIONCONCLUSIONREFERENCES |
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Collaboration is one of the cornerstones of health promotion, with the literature indicating a range of circumstances under which it can either succeed or be undermined. In New Zealand in the 1990s, a market structure for health made collaboration of all kinds exceptionally difficult. This paper traces the efforts of a group of nutrition agencies (Agencies for Nutrition Action) to defy the popular wisdom and persist with collaborative efforts. The agencies were unsuccessful in their attempts to develop joint campaigns, but were very successful in advocacy and intersectoral action that did not threaten the position of individual agencies in the competitive environment. It is possible that the collaboration could have been more effective if agencies had been willing to surrender some autonomy and commit themselves to supporting a more independent new organization. However, this would have compromised not only their individual integrity but also their commitment to a relationship of equals. In ‘holding fast’ to a belief in health promotion, the ANA resisted being coopted by a now discredited market system, and emerged with its integrity and that of its participating agencies intact. ANA is now well positioned to work within an emerging policy environment that is more supportive of health promotion.
Key words: collaboration; health promotion; nutrition
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INTRODUCTION |
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TOPSUMMARYINTRODUCTIONTHE NATURE OF COLLABORATIONTHE NEW ZEALAND CONTEXTRESEARCH APPROACHTHE COLLABORATION EXPERIENCEDISCUSSIONCONCLUSIONREFERENCES |
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Collaboration is ‘a fluid process through which a group of diverse and autonomous actors undertakes a joint initiative, addresses shared concerns or otherwise achieves common goals’ [(Rosenthal, 1998
), p. 246]. In health promotion, collaboration is not just a recognized strategy, but a key value and part of the belief system underpinning health promotion efforts. This had its origins in the Alma Ata Declaration and Health for All [World Health Organization (WHO, 1978; WHO, 1981)], and has been endorsed and operationalized over subsequent decades (WHO, 1986). The health promotion literature has documented some of the inspirational achievements of collaboration, mourned its less successful ventures and continues to work to enhance the capacity of policy makers and practitioners to ensure collaboration works (Walker, 1992; Delaney, 1994; Gillies, 1998). The justification for the preoccupation with a time-consuming process that is hard to evaluate, and that requires high levels of commitment and energy from participants, with sometimes uncertain returns, lies in the belief that collaboration creates a whole that is greater than the sum of its parts. This yields intrinsic as well as substantive benefits for health, and is a way of working that enhances, empowers and gives meaning to the work and lives of those who engage in it.
This paper provides a case study of an initiative to develop and maintain collaboration for promoting healthy lifestyles, particularly through nutrition and exercise, in New Zealand in the 1990s. This initiative, Agencies for Nutrition Action—Nga Takawaenga Hapai Kai Hauora (ANA) was grounded in health promotion theory and intersectoral collaboration, and was supported by a health service tradition of the 1980s that valued integration and goal orientation (Fear, 1991; Beaglehole and Davis, 1992). It was implemented in a health system of the 1990s that had adopted a market approach, even for health promotion, with a tendency towards competition and fragmentation (Barnett and Malcolm, 1998). Despite this environment, ANA survived through the 1990s and contributed to the promotion of healthy lifestyles. There is an intrinsic interest, therefore, in the ANA case study, but more importantly it represents an instrumental case (Stake, 1994) by illuminating issues around collaboration and the strategies necessary for working in a difficult environment.
This paper briefly reviews collaboration concepts and points out the importance of environmental as well as theoretical frameworks. It outlines the New Zealand health environment of the 1990s, with the body of the paper examining the formation of ANA and its work during this period, reflecting on both collaboration theory and the environmental context. The paper finally draws conclusions about the implications of the ANA experience and makes suggestions for agencies considering collaboration in less than propitious circumstances.
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THE NATURE OF COLLABORATION |
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TOPSUMMARYINTRODUCTIONTHE NATURE OF COLLABORATIONTHE NEW ZEALAND CONTEXTRESEARCH APPROACHTHE COLLABORATION EXPERIENCEDISCUSSIONCONCLUSIONREFERENCES |
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There are three main ‘streams’ of literature relevant to collaboration in health promotion. First, from time to time, there are papers in the health promotion literature that make important contributions to the debates about collaboration (Delaney, 1994
; Gillies, 1998). Secondly, examples of specific sectoral collaborations appear in specialist journals (Means et al., 1991; Chokalingham et al., 2000; Robbins and Krakow, 2000), but nevertheless have important messages for health promotion practitioners in the wider field by elaborating case studies from particular areas. Thirdly, there is a wider literature on collaboration, with important insights available from other disciplines such as organization theory and business management (Scholpler, 1987), or other policy sectors where interorganizational relationships are important (Morgan, 1995; Poncelet, 2001). Experienced commentators indicate that such relationships ‘are difficult to manage and often fail to meet expectations’ [(Huxham and Vangen, 2000), p. 2].
Developing coherent expectations of collaboration from the literature is assisted by recent helpful reviews by Rosenthal (Rosenthal, 1998) and Gillies (Gillies, 1998) who, while focusing on health, also drew on the broader theoretical literature and experience. This is used here, along with more specific sectoral literature, to identify three themes—motivation and leadership, management systems and implementation activity—which provide the framework for understanding collaboration in health promotion.
Motivation and leadership
The founding phase of any collaboration requires motivation, which may derive from diverse sources. On the one hand, threats in the environment may stimulate collaboration as a way of ensuring protection, legitimacy or preservation of resources (Rosenthal, 1998). Alternatively, collaboration may be encouraged by a facilitative or propitious environment. In both cases, collaboration may be altruistically motivated and based on values or social purpose. Regardless of the environment or motivation, leadership is essential for collaboration to occur. This may be either entrepreneurial leadership ‘from the front’ or facilitative leadership that emerges from some group process (Zander, 1985). In both cases, leadership will articulate a collective vision as the basis for agreement on joint goals and the decision to collaborate.
Management systems
The literature on interorganizational networks suggests than even when vision and values are shared, inevitable tensions arise from being a member of both a collaboration and a ‘home base’ organization (Delaney, 1994). Developing systems to deal with these requires consideration of the type of collaboration and associated governance arrangements. Rosenthal, for example, identifies three frequent collaboration arrangements: strategic partnerships; service integration; and comprehensive collaborations (Rosenthal, 1998). Strategic partnerships involve no intermediate organization and rely on direct bilateral relationships between organizations. Service integration involves the coordination of independent activities into one system and is based on a desire to reduce fragmentation. Comprehensive collaborations attempt to create an inclusive environment for advocacy, planning, resource creation and service activity. Clearly these represent increasingly complex arrangements, carrying different risks and requiring particular management systems for effective execution. The extent to which a collaboration can develop management systems that ‘match’ aspirations will be a critical factor in effectiveness.
Implementing the collaboration
Implementing collaboration involves detailed planning to achieve outcomes, resourcing teams, undertaking specific tasks, adjusting activities where necessary and making repeated decisions about the best way forward. The environment and external relationships will be an enduring influence of the implementation of a collaboration (McAdam et al., 1988; Rosenthal, 1998). Of particular importance for health promotion will be the degree of emphasis on market approaches. While Catford identified both constraints and opportunities of the market for health promotion, constraints such as the potential for increased fragmentation, lack of cooperation, inability to share ideas, and ‘tribal warfare’ (Catford, 1995) posed particular risks for collaboration. This suggests that while the general framework for collaboration will be an important tool for analysing the progress of ANA, it is also necessary to elaborate the context in which events occurred.
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THE NEW ZEALAND CONTEXT |
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TOPSUMMARYINTRODUCTIONTHE NATURE OF COLLABORATIONTHE NEW ZEALAND CONTEXTRESEARCH APPROACHTHE COLLABORATION EXPERIENCEDISCUSSIONCONCLUSIONREFERENCES |
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During the 1980s there were increasing efforts in New Zealand to develop an integrated approach to health promotion, drawing state-funded public health services and a range of non-government organizations (NGOs) into closer relationships. Sector restructuring created 14 area health boards in 1989, each with a brief to include the non-statutory sector in their development activities, which a number agreed to do (Fear, 1991
). Central policy placed high value on public health and health promotion through the promulgation of Health Goals & Targets and the New Zealand Health Charter (Beaglehole and Davis, 1992), with lifestyle issues being a significant part of this thrust (Fear, 1991).
In 1991, a new conservative government announced a radical policy departure, creating an internal market for health with the provision for competition between providers and contracting for services (Upton, 1991), and rejecting some features of the recent past, including collaborative strategies and an emphasis on health goals. The sequence of events for public health and health promotion, which were separated from other health services organizationally, is set out in Table 1. Concerns about the impact of a competitive contracting environment on this sector were somewhat alleviated initially by the presence of an independent high-profile policy and purchasing agency, the Public Health Commission. Unfortunately the Commission, which had issued a draft Plan for Nutrition Action (Public Health Commission, 1994), fell foul of both its fellow (but competing) policy agency, the Ministry of Health, and the government, whose allies in the commercial sector included alcohol, tobacco and some food producer interests hostile to public health advocacy (Barnett and Malcolm, 1998). In addition, as one of several agencies purchasing public health services, the Commission was seen as contributing to increasing fragmentation among both NGO and public providers (Public Health Association of New Zealand, 1994; Malcolm et al., 1996). NGOs were under particular pressure as traditional sources of charitable funds declined and agencies found the environment increasingly confusing (Swinburn, 1999). In 1995 the Public Health Commission was abolished, creating additional uncertainty among providers. This confusion was exacerbated by the general election of 1996, with a Centre-Right coalition government returned in which the minority partner had campaigned strongly against market approaches to health. In fact, from 1997 to 1999 there was a progressive retreat from competition and support for collaboration (Gauld, 1999). In 1999, yet another change of government (Centre-Left coalition) led to further restructuring towards a more collaborative system, with the development of a national health strategy which includes nutrition goals (Ministry of Health, 2000).
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Within this ‘turbulent decade’ (Hornblow and Barnett, 2000
), five organizations (Cancer Society of New Zealand, National Heart Foundation of New Zealand, the New Zealand Nutrition Foundation, the New Zealand Dietetic Association and Te Hotu Manawa Maori) formed ANA. They were joined later by the National Diabetes Forum, and sought to promote healthy lifestyles through collaboration. The Ministry of Health and the Hillary Commission (a statutory agency encouraging active recreation) became members with ‘observer’ status. |
RESEARCH APPROACH |
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TOPSUMMARYINTRODUCTIONTHE NATURE OF COLLABORATIONTHE NEW ZEALAND CONTEXTRESEARCH APPROACHTHE COLLABORATION EXPERIENCEDISCUSSIONCONCLUSIONREFERENCES |
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The following sections develop a qualitative case study of ANA. Despite the understanding of a case study as a ‘unique and bounded system’ [(Stake, 1994
), p. 237], this system includes the context in which the case occurs. This research, therefore, links the collaboration experience and environmental context outlined above, with both the events of the health sector and stages of the collaboration set out in Table 1
. The case study itself draws on four data sources: (i) ANA records, which were comprehensive and opened without restriction to the authors; (ii) interviews with nine key informants who had been formally involved in ANA, either as staff or representing collaborating or observer agencies; (iii) government documents; and (iv) published research on the ‘turbulent decade’ (1990–1999). This variety of sources enables triangulation of data and confirmation of sequencing and relationships. The analysis was according to the collaboration ‘themes’ of (i) formation and leadership, (ii) managing the collaboration, and (iii) implementing collaboration activities. Both authors were involved in the analysis; one had been part of ANA and the other had not, bringing a balance of informed ‘insider’ and independent ‘outsider’ perspectives. Similarly, preliminary versions of the analysis and the draft paper were reviewed by both ANA ‘insiders’ and critical ‘outsiders’. While the findings are reported in a systematic way, reflecting the analytical themes, there is also an element of time sequencing which links the collaborative processes with the events in the environment. |
THE COLLABORATION EXPERIENCE |
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TOPSUMMARYINTRODUCTIONTHE NATURE OF COLLABORATIONTHE NEW ZEALAND CONTEXTRESEARCH APPROACHTHE COLLABORATION EXPERIENCEDISCUSSIONCONCLUSIONREFERENCES |
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Motivation and leadership
Key informants reported that when representatives of the five NGOs began meeting in 1993, the two main reasons for forming a collaboration were to provide ‘consistent nutrition messages’ for consumers who were thought to be receiving different information reflecting the biases of participating organizations (heart, cancer, etc.), and to provide a vehicle for a combined and effective voice on nutrition matters. ANA documents confirm that collaboration was expected to maximize effectiveness of individual agencies through a coordinated effort, through acquiring resources for ANA itself to develop and manage new projects, and through influencing government agendas. While the three themes, coordinated effort, joint projects and advocacy, are apparent in ANA documents, key informants gave emphasis to the first two, and attached lesser importance to advocacy as a motivating factor.
Key informants reported that the overall vision of collaboration was supported by two facilitating influences. First there was the participating agencies’ commitment to health promotion and the value of collaboration to support that ethos. The competitive structure of the health sector and a need for ‘safety in numbers’ did not appear to be an important motivating factor compared with the perceived health promotion benefits expected from the venture. Secondly, there was the significant leadership role of individuals from member organizations who were seen to have the professional standing and authority to commit their organizations to a formal collaboration. The significance of this was to emerge later when key informants reported that the competitive structure of the health system had been accompanied by both personnel and culture changes in some participating agencies, with the emergence of a more corporate or ‘organization-centric’ climate, with less priority attached to collaboration.
Management systems
Although the agencies had been working together informally and met regularly since 1993, only in 1995 did they all agree formally to participate in ANA and set up an incorporated society. A number of systems were put in place to increase capacity, provide a structure and maintain relationships. Initially, seeding funds were sought from each member organization in the form of a cash contribution or coordination time additional to the normal time contributed by representatives. Each agency then made an annual financial contribution, with additional funds sought through sponsorship for specific activities and contracts with government agencies. Employment of an executive officer increased capacity and relieved participants of the burden of sustaining ANA as well as fulfilling their roles with their home organizations. Despite these efforts, six of the nine key informants reported that lack of consistent and sufficient funds and personnel continued to detract from ANA’s efforts.
The systems for managing relationships involved a management committee with one representative from each member organization. This approach was tested early on when all participating agencies were able to bid for the government contract, previously held by the National Heart Foundation, to support national nutrition guidelines. Interested agencies submitted independent bids, often with external partners, with the National Heart Foundation retaining the contract in the face of stiff competition. Open discussion followed, with disappointment expressed that ANA had not put in a collective bid. An analysis of ANA documents confirms that considerable time and energy was expended in dealing with differences between member organizations around this time. Nevertheless, openness in communication about such tensions and the high level of trust between participating members were both identified by key informants as important in maintaining the stability of ANA. However, members struggled at times to balance commitment to the collaborative cause with the requirements of their own organizations, including the need to maintain agency identity and ‘brand.’ Lack of commitment, inconsistent vision, and tensions between the member groups were noted by six of the nine informants to be present at a level that constrained ANA. Examples cited included: ‘Self-centred view of some member organizations’ and ‘Competing for contracts and sponsorship’. One respondent commented:
There was a basic mismatch between expectations of members. At least two organizations wanted ANA to run a collaborative campaign to which all contributed funding and services; others wanted ANA to do advocacy so that they could run their own campaigns.
Pursuit of collaboration
An early strategic objective for ANA, adopted for 1994/1995, was to address obesity in the community. This priority topic was strongly supported by member organizations but not recognized at that time as significant in government policy. An ambitious community campaign was planned to encourage the maintenance of healthy body weight, targeted towards 18- to 24-year olds. By late 1994, research on the perceptions of young people towards maintaining a healthy body size was used by an advertising agency to develop a communication strategy to be implemented by ANA. This comprehensive approach was undermined by uncertainty about government support, the loss of member organization personnel who had ‘championed’ the ANA cause, and difficulty in raising funds either from member organizations or externally. It also received a negative response from food industry marketers who were invited to fund the strategy.
Plans for the campaign were put ‘on hold’ in mid-1995, and the collaborative efforts of ANA were channeled instead into developing two documents as tools for advocacy of obesity prevention. The first, a consultation document entitled Healthy Weight in New Zealand—Taumaha Tika Aotearoa, outlining the obesity epidemic in New Zealand, sought comment on a national population-based prevention strategy (Agencies for Nutrition Action, 1996). The second paper, The Health Care Costs of Obesity in New Zealand (Swinburn et al., 1996) estimated the health care costs attributable to obesity for the major obesity-related health problems. With these tools in place, ANA made its advocacy debut, heightening awareness among media, government and the community about obesity and how it might be tackled, including appearing before a government advisory committee. The official launch of Healthy Weight New Zealand captured the attention of both government and media, and in September 1996 ANA secured its first government contract, to complete consultation on the document and prepare a final version.
From 1995–1997 ANA focused increasingly on its advocacy role, receiving contract funding to develop its intersectoral activities and praise from government policy makers for its initiative. Intersectoral advocacy involved engaging a number of sectors (food industry, media, physical activity and education groups, Maori and Pacific peoples) in a national forum to explore weight issues. Nutrition Action New Zealand emerged as the umbrella title for an intersectoral framework to link groups and activities (Figure 1), with ANA launching a newsletter and website and leading regional forums. The outcome of these advocacy efforts was the inclusion of obesity issues, for the first time, in national health goals and targets (Ministry of Health, 1998).
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Despite the success of the advocacy and intersectoral strategies, the desire to collaborate on a major campaign remained strong with some member organizations, and early in 1998 steps were taken to develop a targeted programme for 25- to 40-year-old men, known as the Fit Food Challenge. This failed to attract an adequate level of sponsorship, with the resulting campaign downsized at short notice to fit a modest budget pieced together from a variety of sources. This experience reinforced the view that ANA did not have the capacity to resource or manage campaigns of this magnitude, and highlighted the mismatch between the expectations of members.
Key informants were asked to assess the success of the three strategies. Overall, they indicated that good progress had been made in coordination and the attempt to develop a combined voice and consistent nutrition messages, although almost all expressed reservations, such as:
Some improvement in consistency of messages achieved, but ANA has rarely been able to speak on behalf of the organizations; and
Some headway with more consistent messages, but the groups still need to do their own thing ...
With respect to new collaborative project work, such as the obesity campaign, ANA documents indicate little progress, with key informants largely endorsing this view:
Very limited success in getting ‘on the ground’ activity under way.
In contrast, advocacy in the area of obesity was acknowledged by all informants to have been largely successful with two significant outcomes. First, the participating agencies found the success of advocacy an enabling experience in an area where they had seen themselves as previously ineffective, justifying and confirming their commitment to collaboration. Secondly, there were clear indications of successful policy outcomes. Key informants confirmed that if ANA had not been active, the issue of obesity would not have achieved early prominence on the policy agenda. This was demonstrated by the presence, for the first time, of obesity within the national health goals and targets framework, and specific recognition of ANA’s role by the Ministry of Health:
National and regional meetings [held by ANA] are part of consultations on a national strategy to promote a healthy body weight. These and other activities [by ANA] have resulted in increased awareness of the health implications of obesity among New Zealanders [(Ministry of Health, 1998
The Minister of Health, Hon. Annette King, also commented on the impact of ANA:
In recent years the leadership and coordination role in promoting healthy weight for New Zealanders has been provided by ANA ... I will be looking forward to the Ministry of Health ... continuing to work closely with ANA (King, 2000
In the most recent government policy statement, the New Zealand Health Strategy (Ministry of Health, 2000), obesity is one of 13 priority health goals.
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DISCUSSION |
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TOPSUMMARYINTRODUCTIONTHE NATURE OF COLLABORATIONTHE NEW ZEALAND CONTEXTRESEARCH APPROACHTHE COLLABORATION EXPERIENCEDISCUSSIONCONCLUSIONREFERENCES |
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In terms of the literature on collaboration, nutrition agencies were clearly motivated by an altruistic desire to be effective in health promotion, reflecting values of international initiatives such as the Ottawa Charter, and were not, as might have been anticipated, responding defensively to the threat of competition. In fact, the agencies were confident of the value and integrity of the collaborative approach and perhaps did not initially realise the extent to which the market policies would undermine their efforts. The systems ANA developed to manage inter-agency relationships did not prove fully adequate to deal with the tensions created by competition and the varied expectations of agencies. The multiple collaboration goals (cooperation, collaboration and advocacy) may have required, as Rosenthal pointed out, a more independent structure to deal with the management of new projects (Rosenthal, 1998
). The role of leadership in ANA was well recognized, and considered a critical factor in the ability of the organization to survive. While the leadership was highly facilitative it continued to be home-organization centred. For collaboration to flourish in a competitive environment, a more entrepreneurial style of leadership may be required which is of high status but independent of any of the interested parties. Possibly this may also need to be accompanied by decision-making arrangements that are not dependent on continuing consensus, but which rely on some agency autonomy being formally surrendered to the collaboration.
The implication of both leadership style and management systems was that only a portion of the agreed objectives were successfully implemented, with a strong consensus that nutrition advocacy, initially identified as the least important goal, had been highly successful, with the other two aspirations less so. Nutrition advocacy, hitherto an undeveloped area, did not challenge the autonomy and existing interests of individual agencies, and was more readily endorsed by all members. Advocacy, with its intersectoral component, was arguably a more important and innovative achievement than the aspiration towards a joint campaign. Advocacy coalitions have played a significant role in advancing policy change in New Zealand in recent years (Fear, 1999), particularly when issues are contentious. The AIDS support network of the early 1980s, for example, had to contend with a hostile legal environment and equivocal bureaucracy (Plumridge and Chetwynd, 1994). Anti-smoking collaborations of both the 1980s and late 1990s, despite the weight of scientific evidence, had to counter the might of the tobacco companies (Thomson and Wilson, 2000). For these, the cause itself was the contentious issue and enhanced the solidarity of the collaboration. Although in many ways nutrition advocacy could be seen as an acceptable cause; for ANA, however, the market environment was both inimical to collaboration and endorsed an individualist philosophy that undervalued collective action for lifestyle change.
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CONCLUSION |
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TOPSUMMARYINTRODUCTIONTHE NATURE OF COLLABORATIONTHE NEW ZEALAND CONTEXTRESEARCH APPROACHTHE COLLABORATION EXPERIENCEDISCUSSIONCONCLUSIONREFERENCES |
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ANA managed to negotiate its way through the 1990s on the strength of values, facilitative leadership and minimalist management systems. This research confirms that collaboration is never easy, with considerable time and energy spent managing the internal tensions of being a member of a collaboration and home-base organization. In addition, the research points to the additional external pressures on collaboration imposed by the market approach, such as the need for individual strategies or secrecy in order to gain advantage in competing for both contracts and sponsorship.
Some aspects of ANA’s collaborative efforts may have benefited from a more realistic approach to the environment, a more entrepreneurial leadership style and more independent management systems. However, such alternative arrangements may, in fact, have had a detrimental effect, involving a type of commitment probably unacceptable to the agencies, and seen by them as inconsistent with the type of collaboration to which they subscribed. The health promotion values to which they adhered included interdependence, equality in relationships and partnership, and the surrender of agency autonomy would have compromised their integrity as NGOs. In our view, the inability to pursue the obesity campaign in no way undermined the success of ANA, but ensured that its efforts were redirected to the more innovative areas of advocacy and intersectoral action, in which it could play a unique role. In ‘holding fast’ to a belief in health promotion, the ANA resisted being coopted by a now discredited market system, and emerged with its integrity and that of its participating agencies intact.
Healthy Weight New Zealand was relaunched in 2001, and ANA is regarded as a leader in the nutrition and lifestyle field. Despite its successes, however, ANA now has to face further questions about its future. The latest health reforms, while supportive of health promotion, intersectoral action and collaboration, are based on decentralized, district-level structures. It might seem that, despite a more propitious climate for action on nutrition, such decentralization could undermine the role of national collaborations such as ANA. However, the experience of ANA suggests that national efforts to encourage intersectoral activity can assist collaboration at the local level and facilitate the work of small capacity organizations. While the changing environment continues to be an important influence, the flexibility and responsiveness demonstrated by ANA over the last decade can again be called into play. The lesson from the 1990s is clear: while flexibility and responsiveness are important, it is maintaining integrity of purpose and a refusal to compromise the values of health promotion and collaboration that provide the platform for effective action.
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ACKNOWLEDGEMENTS |
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The authors wish to acknowledge the support of the staff and committee of the Agencies for Nutrition Action who kindly made themselves and their documents available to this research. Sue Zimmerman, Boyd Swinburn, Jill Nuthall and Pamela Williams kindly reviewed the paper, and we appreciate their constructive comments.
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