Regulating alcohol packaging and supply to protect health in Sub-Saharan Africa: evidence from policy systems in Malawi and Uganda

Consuming alcohol ('drinking') causes cancers and other NCDs globally and more than 3 million people died due to harmful use of alcohol in 2016 (1 in 20 deaths). It has impacts on economic productivity and can lead to addiction, violent behaviours, injuries, and road-traffic collisions. It also impacts on health systems, particularly in low and middle income countries (LMIC) where those system already face significant challenges. Drinkers in Africa consume 21% more alcohol per day than the global average. Small disposable plastic sachets which contain alcohol or spirits have led to significant alcohol abuse amongst the most vulnerable and poorest communities in Malawi and Uganda, particularly the young. As a result Malawi and Uganda placed national bans on sachets of alcohol in Malawi (2016) and Uganda (2019), but those may not have had the impact anticipated. In March 2019, we organised a workshop with researchers from 6 LMICs including Malawi and Uganda to discuss issues around alcohol consumption and what research could be done to supports effective policies to control the supply of alcohol. The issue of the alcohol sachets and the policies to ban them was raised by Malawi and Uganda colleagues, who felt it was needed to study the implementation of the bans, to compare both countries and to see what lessons could be learnt.

Our aims with this study are to understand why the bans were adopted and how they were presented, what mechanisms for implementation were proposed and put in place, how the bans were enforced in practice, and what unintended consequences may have occurred. We will do this through interviews with policy makers and major stakeholders, and also, through interviews with district and local stakeholders in enforcement and trade. We will also conduct focus group discussions with men and women, health staff from local health centres and with traditional/ church leaders and school headteachers, to explore the perceived impact of the ban on harmful forms of alcohol consumption and any unintended consequences of the bans (e.g. increased consumption of home brews). We will also examine perceptions of changes in harmful drinking within the community and amongst young people; and whether local health facility staff have seen changes in terms of addiction and harm at facility level because of the bans. We will share our results with stakeholders at special events in Malawi and Uganda.

To achieve our aims we have assembled a team of seven highly experienced researchers from different disciplines (social science, epidemiology, psychology, population, and public health). Four of them are based in Uganda and Malawi where they will lead the research and two in South Africa. We will recruit full-time researchers in Uganda and Malawi to carry out the work and will train them to have the confidence to carry out alcohol research which can influence policy and help reduce alcohol-related harms. We have also assembled an international advisory group with 2 experts from high income countries and 7 from African low and middle income countries networks on alcohol We will work closely with stakeholders in each country and other African and global networks from start to finish, to give them an opportunity to understand our findings in their context, so they can use those findings in policy development, for advocacy, and to support further research.

The age-standardized alcohol-attributable burden of disease and injury is highest in the WHO African Region, at 70.6 deaths and 3 044 DALYs per 100 000 people, placing an enormous strain on already challenged health systems. Drinkers in Africa consume 21% more alcohol per day than the global average. Small disposable plastic sachets- pouches which contain single use quantities of alcohol which often contain 40% spirits- have led to significant abuse amongst the most vulnerable and poorest communities in Malawi and Uganda. Concerns about harmful consumption and the public health and societal impact led to national bans on sachets of alcohol in Malawi (2016) and Uganda (2019), but those may not have had the impact anticipated.
We will conduct interviews with key policy stakeholders and with district and local stakeholders in enforcement and trade in Malawi and Uganda to understand the adoption and formulation of the bans, what mechanisms for implementation were proposed and put in place, how the bans were enforced in practice, and any unintended consequences that have resulted. We will conduct focus group discussions with community members, health staff from local health centres and with traditional/ church leaders and school headteachers to explore the perceived impact of the ban and any unintended consequences from a local community perspective.
Our multidisciplinary international team will conduct a robust analysis based the Health Policy Analysis framework to highlight contextual factors important for the transferability of findings to other Sub-Saharan countries in order to inform alcohol policy development and implementation across the region. We will publish results in peer reviewed journals and share them at stakeholder events in each country to discuss how the results may be used to further regulation of the supply of alcohol and reduction of related harms. Our researchers in LMICs will benefit from a strong capacity-building and research skills programme.