Analysing the policy and governance environment for NCD control, and identifying potential policy options.

Lead Research Organisation: University College London
Department Name: Institute for Global Health

Abstract

The Non-Communicable Diseases (NCDs) have emerged as the most important global threat to human health and wellbeing. Four major NCDs - heart disease, cancers, diabetes, respiratory diseases - cause the deaths of 38 million people every year, of whom 16 million die prematurely (under the age of 70 years). These diseases cause chronic illness and disability and are a source of suffering and financial hardship for individuals, families, communities and health systems struggling to provide continuous care for people with long-term health problems. The NCDs affect populations across the globe - and they are now the leading cause of death in many low and middle income countries.

Many of these diseases are driven by exposure to commercial products - tobacco, alcohol, highly processed foods (including the so-called 'junk foods') which have high levels of salt, sugar and/or trans-fats. Evidence shows that limiting exposure to these products is likely to bring health benefits, but it is often very difficult for individuals to sustain 'healthy behaviours' over their lifetime. Evidence-informed prevention strategies most likely to bring benefit to the largest numbers of people include: regulating exposure, e.g. taxation on products known to be health-reducing, such as sugary drinks; restricting access, e.g. no sales of tobacco to children, non-smoking zones in public spaces; or reformulating products to make them less likely to cause harm, e.g. lowering the salt content of processed foods. Such strategies, when implemented well, can have a significant impact on improving population health.

However, Governments face many challenges in implementing these policies - for example, there may be resistance from strong and powerful commercial companies that have a vested interest in selling their products. Moreover, in many countries, there is little policy experience in tackling the NCDs.

In this project we propose to undertake detailed policy analyses to identify acceptable and feasible options for Governments in both low- and middle-income countries to tackle the growing burden of NCDs in their countries. Our work will focus on three policy areas - control of sugar, salt and trans-fats in processed foods. We will work with researchers in Afghanistan, Bangladesh, Iran, Nepal, Pakistan, Tunisia and Vietnam to identify how the Government in each country is currently tackling NCDs. We will then map out the influences on policy options operating in each country. Such influences are likely to include the role of powerful stakeholders such as the food producing and selling industries, the media, the medical establishment, the Ministry of trade, etc. We will also identify whether any civil society groups (in some countries this might mean, for example, groups of parents concerned about junk-food marketing to children; in other countries it will include groups of patients suffering from diet-related NCDs such as diabetes) are working on policy issues. We will conduct interviews with key stakeholders to better understand the opportunities for seeing effective policy implemented for controlling sugar, salt and/or trans-fats, as well as identifying the challenges and barriers to putting effective policy options into operation.

This kind of health analysis requires a specific skill set which is not common in many countries. As part of our project we will therefore establish and strengthen the capacity of a network of researchers from all 8 countries (including the UK), who will support each other to carry out the analyses and interpret the findings. We will foster cross-learning of policy successes between different countries. In addition, we will promote engagement and dialogue with a wide variety of stakeholders in each country throughout the lifetime of the project in order to ensure that the findings of the research carry meaning and weight in policy decisions to improve population health both in the 7 research countries and beyond.

Technical Summary

Non Communicable Diseases (NCDs) represent the largest and fastest growing threat to human health, including in low- and middle-income countries (LMIC). The Global Burden of Disease (GBD) project reports that in the Middle East North Africa (MENA) NCDs are the most significant contributors to both burden of disease and causes of death. In MENA and South and Southeast Asia epidemiological transitions have seen infectious diseases becoming less burdensome over the past 20 years, and the NCDs now major killers even in the poorer countries.
While the health system can play an important role in treating symptoms and complications of NCDs it has less leverage in addressing the determinants of NCDs themselves, and universal access to NCD treatment will bear a prohibitive price tag for any country - including the wealthiest ones. Effective prevention interventions are urgently needed, and rigorous evidence from WHO suggests these should be focused on addressing policy and regulatory environments for NCD risk exposure at a population level. However, governance of NCD determinants can bring public health communities into conflict with the for-profit private sector producing, for example, highly processed foods replete with salt, sugar and trans-fats. We have very little information about potential governance/policy models that are likely to be feasible, acceptable and effective in ensuring that WHO's "best buy" policy options for NCD control are implemented.

Planned Impact

Our ultimate goal is to see more effective evidence-informed public policies in place for controlling non-communicable diseases (NCDs). This is a long term goal, but shorter term benefits will accrue from a better understanding of health policy processes in our partner countries, including identifying levers and opportunities for policy influence. We will work in 7 low- and middle-income countries that, while all ODA-recipient, nonetheless present a range of economic, political and policy-making environments. A benefit of our approach is the potential for cross-learning. The main beneficiaries of this project are all those who are concerned with evidence-informed policy-making to improve population health. In particular:

1. Key decision-makers within health policy making processes in 7 partner countries. Our research will focus on NCDs which are currently relatively low on the health policy agendas of many LMIC and have received proportionately less policy and resource attention compared to other health issues up till now. We aim to better understand what influences health policy decision-making in selected LMICs, and through direct engagement with decision-makers, to identify the extent to which they are both aware of the extent of empirical evidence around NCD control, and the extent to which they are able to act on the evidence. We will engage with decision-makers at all stages of the project (i.e. not just at the end), which will carry the following benefits:
a. Increase in awareness of the burden (individual, economic, impact on health system) of NCDs in their country, and available policy options for prevention;
b. Identification of key allies in promoting evidence-informed policy making. Such allies may lie outside of the direct policy-making arena and include sympathetic media outlets, civil society organisations, etc.
c. Promoting cross-country learning including of positive policy options

2. Key decision-influencers. Our stakeholder mapping and analysis in each country will identify those who make health policy for NCD control (focusing on sugar, salt and trans-fats), as well as those who have an influence on policy - for example, media outlets concerned with issues of population health, civil society organisations, industry bodies concerned with promoting 'healthier' options (e.g. those with reduced sugar or salt levels). We will engage with these stakeholder groups as an ongoing activity through the lifetime of the project, and expect this to have the following benefits:
a. Access to rigorous (academic) evidence that can be used in the ongoing work of beneficiaries concerned with NCD prevention and control. Such evidence may include identification of high impact policy options for NCD control, and, conversely, which promoted policy options are not supported by rigorous evidence.
b. Better understanding of policy-making networks and processes so that beneficiary resources and activities can be targeted to institutions (and possibly to individuals) where influence and impact is likely to be highest.

3. Global health institutions concerned with NCD prevention and control. The multi-country nature of both the network and the research allows for the identification of NCD policy challenges and opportunities that are common across national boundaries. Such policy issues are likely to include findings on the role of global networks seeking to influence NCD/diet policies at both global and national levels.

Much of the research will carry immediate benefits in terms of increasing understanding of NCDs, and both national and global influences and challenges to evidence-informed policy-making and policy implementation. Capitalising on this information to actually promote strategies and activities for evidence-informed policy making is a longer-term goal beyond the lifetime of a 2-year project, but will form the basis of future action from the network of researchers involved in this project.
 
Title Children's videos capturing their food environments 
Description We have worked with school children in 7 countries (our 6 collaborating countries plus the UK) to engage their understanding of their food environments and food choices, 
Type Of Art Film/Video/Animation 
Year Produced 2020 
Impact The videos have been picked up by the media and resulted in an article in The Guardian and a Radio 4 interview. 
URL https://www.healthysocieties2030.org/films
 
Description We have analysed public policies to promote healthy diets in 6 low- and middle-income countries and discovered that Government policies are frequently comprehensive, but often do not have many of the characteristics associated with the likelihood of an effective policy that will work to improve people's health. Policies were frequently of low status (strategies rather than laws, for example), did not target the most vulnerable in society, and did not use any of the approaches that have been successful in other areas of public health. Successful approaches have included involving communities and civil society to promote change, and drawing on the power of human rights instruments to improve population health. The absence of such approaches is likely to hinder the delivery of healthy food environments around the world.
Exploitation Route The outcomes have relevance to a variety of audiences:

1. Academics - development of a new framework for assessing health policy: https://doi.org/10.1093/heapol/czz175
2. Policy-makers - https://www.theguardian.com/global-development/2019/dec/26/coke-crisps-convenience-how-ads-created-a-global-junk-food-generation
3. Civil society and communities - https://www.healthysocieties2030.org/films
Sectors Agriculture, Food and Drink,Communities and Social Services/Policy,Healthcare

URL https://www.healthysocieties2030.org/ncds/policy
 
Description Given that policy change itself takes many years to materialise, we nonetheless believe (as noted in our original theory of change) that civil society demand can foster positive policy developments. It is therefore extremely pleasing that the public engagement outputs generated through this project, namely videos co-produced by children in six countries to describe their food environments, have stimulated a great deal of media and public interest (as shown through coverage in print and social media). We envision that these videos will continue to encourage debate, discussion and action to strengthen diet-related NCD policies in relevant countries.
First Year Of Impact 2020
Sector Healthcare
Impact Types Cultural

 
Description Effective public policy for improving sexual health of migrants/refugees
Amount £673,516 (GBP)
Funding ID 208712/Z/17/Z 
Organisation Wellcome Trust 
Sector Charity/Non Profit
Country United Kingdom
Start 01/2017 
End 02/2021
 
Description GCRF
Amount £8,000,000 (GBP)
Organisation Research Councils UK (RCUK) 
Sector Public
Country United Kingdom
Start 01/2018 
End 12/2021
 
Title New mode for analysing the content of health policy 
Description Based on learnings from our six-country study of health policy related to NCDs and healthy diets, we have developed a new model for analysing health policy content. Called the 'policy cube' this has now been published in the top journal for health policy (Health Policy and Planning) and has been well received by researchers and the policy community more generally. We are now receiving enquiries from civil society, researchers and policy makers regarding the application of this new method of analysis to other areas of public health (particularly with regards to the control of alcohol). 
Type Of Material Data analysis technique 
Year Produced 2020 
Provided To Others? Yes  
Impact We are now receiving enquiries from civil society, researchers and policy makers regarding the application of this new method of analysis to other areas of public health (particularly with regards to the control of alcohol). 
URL https://doi.org/10.1093/heapol/czz175
 
Description Advancing the Agenda 
Organisation Joint United Nations Programme on HIV/AIDS (UNAIDS)
Country Global 
Sector Public 
PI Contribution We participated in the establishment of a consortium of reseachers, academics, policy makers, politicians and civil society organisations to discuss the shifts needed to achieve the Sustainable Development Goal for Health. Participants at the meeting, held at UCL in November 2017. This partnership addressed the question: "What would a more strategic and coordinated approach to supporting countries to ensure that people not only survive but that populations can prevent disease and stay healthy?" We organised a day-long discussion organised around a shared concern that the global health system is not well set to effectively address the structural, social and commercial determinants of the major emerging burdens of disease - particularly the non-communicable diseases and diseases associated with environmental degradation, poor urban planning and unsustainable patterns of consumption. These are the areas of focus for our own MRC-funded research.
Collaborator Contribution Meeting participants identified key opportunities associated with the United Nations Agenda 2030 on Sustainable Development to focus on improving healthy lives, rather than merely survival and disease control. Such opportunities often lie at the intersections of the goals of Agenda 2030, particularly those focusing on health, sustainable production and consumption, strong institutions and gender equality. Partners included Dr Kent Buse of UNAIDS and Dr Anders Nordstrom of the Ministry of Foreign Affairs, Sweden - who gave financial support from the Swedish Ministry of Foreign Affairs.
Impact As a joint partnership we have submitted a Viewpoint to the Lancet, and plan to meet again in Sweden in June 2018.
Start Year 2017
 
Description Advancing the Agenda 
Organisation Swedish Ministry for Foreign Affairs
Country Sweden 
Sector Public 
PI Contribution We participated in the establishment of a consortium of reseachers, academics, policy makers, politicians and civil society organisations to discuss the shifts needed to achieve the Sustainable Development Goal for Health. Participants at the meeting, held at UCL in November 2017. This partnership addressed the question: "What would a more strategic and coordinated approach to supporting countries to ensure that people not only survive but that populations can prevent disease and stay healthy?" We organised a day-long discussion organised around a shared concern that the global health system is not well set to effectively address the structural, social and commercial determinants of the major emerging burdens of disease - particularly the non-communicable diseases and diseases associated with environmental degradation, poor urban planning and unsustainable patterns of consumption. These are the areas of focus for our own MRC-funded research.
Collaborator Contribution Meeting participants identified key opportunities associated with the United Nations Agenda 2030 on Sustainable Development to focus on improving healthy lives, rather than merely survival and disease control. Such opportunities often lie at the intersections of the goals of Agenda 2030, particularly those focusing on health, sustainable production and consumption, strong institutions and gender equality. Partners included Dr Kent Buse of UNAIDS and Dr Anders Nordstrom of the Ministry of Foreign Affairs, Sweden - who gave financial support from the Swedish Ministry of Foreign Affairs.
Impact As a joint partnership we have submitted a Viewpoint to the Lancet, and plan to meet again in Sweden in June 2018.
Start Year 2017
 
Description Dissemination of findings to senior policy makers in Bangladesh 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact As part of the dissemination activities planned for each of the 6 countries involved in our study, a meeting was held in Dhaka bringing together senior policy-makers (e.g. the Mayor of Dhaka City Corporation), researchers and policy-makers. The event was the first time that an opportunity to promote dialogue between children and senior policy-makers had been held in Bangladesh in this way. We had previously worked with the children in a public engagement activity to produce a video about their food environment. This video was shown to the policy-makers along with a more 'usual' presentation of the findings of the study itself.
The event received widespread coverage in the local press (both in Bangla and English language press).
Year(s) Of Engagement Activity 2019
URL https://www.thedailystar.net/health/obesity-increasing-in-bangladesh-younger-generation-1637107
 
Description Dissemination to senior decision-makers from Nepal and Pakistan 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact At the end of our study we brought together senior decision-,makers and politicians from study countries. Owing to political unrest in Tunisia, and the refusal of visas for Afghan participants, we were only able to reach policy-makers from Nepal and Pakistan with our dissemination. However, this provided an opportunity for in-depth discussion of the results of the study over a 2-day period, and fostered a great deal of dialogue on how to implement the findings for policy change in both countries.
Year(s) Of Engagement Activity 2019
 
Description Establishing a social media presence 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact We have established a social media presence to raise the profile of the work of this research project. The social media communications are managed on a regular basis by our UK-based team member.
Year(s) Of Engagement Activity 2017,2018
URL https://twitter.com/NCDsPolAnalysis
 
Description Interview on BBC Radio 4 to discuss the results of the study and implications for controlling childhood obesity 
Form Of Engagement Activity A broadcast e.g. TV/radio/film/podcast (other than news/press)
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Media (as a channel to the public)
Results and Impact We conducted public engagement activities with school children in the 6 countries included in our study as well as with school children at 2 schools in the UK. The purpose of the engagement was to capture the views of the children themselves about their food environments. Such engagement fits with our theory of change that sees public opinion as an integral part of what drives decisions by policy makers. By drawing on the experiences of children and highlighting the challenges of their food environments we aim to stimulate public debate and discourse on how to create healthy food environments for everyone in society. Working with local film makers and our research teams in the 6 countries, we produced a series of short videos that highlight the experiences and environments within which children make food choices. These films have been put on to a publicly available website, and have been accessed by media and policy makers in the UK and beyond. The result has been significant media interest to highlight the role of unhealthy food environments driving poor diets that lead to non-communicable diseases. This resulted in an interview about children and food environments that was broadcast on BBC Radio 4 in February 2020./
Year(s) Of Engagement Activity 2020
URL https://www.bbc.co.uk/programmes/m000f5rk
 
Description Presentation of study findings at Global Conference on Sustainable Food Systems 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact We were invited to present our results at the annual EAT forum held in Sweden. EAT i2019 was a global gathering of over 1000 food system leaders from science, politics, business, civil society and beyond. We (UCL plus one of our collaborators from Nepal) ran a small workshop to highlight the findings from our six-country study and presented the new health policy analysis tool we developed as a result of the study. This has generated a great deal of interest including from civil society organisations, other researchers and the multilateral health system.
Year(s) Of Engagement Activity 2019
URL https://eatforum.org/eatforum19-side-events/
 
Description Production of videos with school children to talk about their food environments 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact We conducted public engagement activities with school children in the 6 countries included in our study as well as with school children at 2 schools in the UK. The purpose of the engagement was to capture the views of the children themselves about their food environments. Such engagement fits with our theory of change that sees public opinion as an integral part of what drives decisions by policy makers. By drawing on the experiences of children and highlighting the challenges of their food environments we aim to stimulate public debate and discourse on how to create healthy food environments for everyone in society.
Working with local film makers and our research teams in the 6 countries, we produced a series of short videos that highlight the experiences and environments within which children make food choices.
These films have been put on to a publicly available website, and have been accessed by media and policy makers in the UK and beyond. The result has been significant media interest to highlight the role of unhealthy food environments driving poor diets that lead to non-communicable diseases. This resulted in an article in the highly read Guardian newspaper.
Year(s) Of Engagement Activity 2020
URL https://www.theguardian.com/global-development/2019/dec/26/coke-crisps-convenience-how-ads-created-a...
 
Description Syntax and the 'sin tax' 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact This blog, based on the findings from our six-country study, pointed out that the framing narrative is a vital part of the feasibility for regulatory control for NCDs in most countries. The blog was picked up by, among others, researchers from BBC radio and contributed to our participation in a Radio 4 Food Programme about childhood obesity.
Year(s) Of Engagement Activity 2019
URL https://blogs.bmj.com/bmj/2019/07/17/syntax-and-the-sin-tax-the-power-of-narratives-for-health/