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

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.

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.

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.