Background
Methods
Policy document review
Stakeholder interviews
Results
Factor | Theme identified (area of respondent) |
---|---|
Nutrition actor network effectiveness | - Absence of actors collectively advocating for change (e.g. leaders, institutions) (2 GOV, RES, 3 IO, DR) vs examples where this has occurred for alcohol restrictions (GOV), MAP development (2 RES), and Multi-sector Nutrition Plan policy community cohesion (IO) - Lack of a forum or network where actors come together to address NCDs (GOV, MED, RES) - People, social leaders need to be vocal and consistently advocate and press for change (RES, CSO) - Based on legalising abortion, need ground up push so Government cannot say no (RES) |
Strength of leadership | - No strong leadership on NCDs, and even less on risk factors for NCDs (GOV, IO) - Health Minister has failed to take a lead; if there is a powerful leader, things get done (2 GOV, RES), e.g. during MAP development (RES) under the previous minister (IO) |
Civil society mobilisation | - Lack of civil society debating and lobbying on NCDs (IO, GOV); NGOs should provide suggestions, put pressure on government to push for policy formulation (2 MED) - Civil society proved important in resisting private sector interference, such as in tobacco (GOV), and in pushing for stronger action from the Nepal Press Council on media content (MED). One CSO respondent considered NGO advocacy along with that of clinicians talking about the rise in the NCD burden in Nepal critical to the government formulating the MAP. - Nepal NCD Alliance talking about the need for action on NCDs (RES), and various other civil society, such as the Nepal Heart Foundation and Nepal Diabetes Society, but they are active in their own spheres, not active as a coordinated group (CSO) |
Strength of institutions | - Lack of multisectoral coordination for the MAP across Ministries (RES, 3 GOV, 2 IO) with for example the high level NCD Committee having only met once since 2014 (IO) - Inadequate government structures (2 RES, 2 IO, GOV, CSO), even though a designated structure for NCDs has been established within the MoHP post federalization (RES) - MoHP has the power for bilateral action, but potentially lacks mandate for multisectoral action (RES, GOV); but some consider that MoHP should lead (GOV, RES) - No one leading on MAP implementation (but everyone is involved), unlike the Multi-sector Nutrition Plan which was led by the National Planning Commission (IO); National Planning Commission should be the executing body for the MAP as many elements outside the control of health, similar to its role in nutrition (2 GOV, IO) |
Effective vertical coordination | - Lack of vertical coordination for the MAP between policy responsibility at the MoHP and implementation by the Department of Health identified, noting that this was not the case previously, potentially due to changed leadership (RES) - Need for regional cooperation to deal with cross-border issues (PS) - Previously demonstrated successful vertical coordination within and external to government in iodisation efforts to address goiter (PS) and in food standard setting (GOV); but also inadequate vertical coordination in implementing tobacco control laws where for example tobacco officers regulating the law do not understand their roles and responsibilities (GOV) |
Societal conditions and focusing events | - Attention diversion at time of the MAP (e.g. the earthquake and federation reform and lack of stability) could have impeded development and implementation (2 GOV, CSO) - Crowded government agenda in health, including the unfinished Millennium Development Goals and the Sustainable Development Goals (IO) - Cross-border media and imports of food from India and China (CSO, PS, IO, DR) create issues in regulating (MED), including due to Nepal’s World Trade Organization membership (MED) - Junk food advertisements from India, e.g. influence of Delhi life, is contributing to changing social attitudes among school students who ridicule home-made foods (GOV) - Now is the time to act (MED), as overweight and obesity has more than doubled in the last 15 years, and access to and use of unhealthy foods has increased (IO, GOV, RES) |
Ideology and institutional norms | - Prevailing beliefs of the need to have sugar in diet to survive (CSO) or that children should eat noodles to ensure they are not malnourished (more common in rural areas) (GOV) - May encounter public resistance in trying to restrict items like biscuits and noodles that have meaning for common people / where strong beliefs around nutrition (PS, DR) |
Credible indicators and data systems | - 5-yearly NCD Risk Factors STEPS survey established to provide clear data and indicators on NCDs (IO, GOV, RES) - Food consumption surveys have not been undertaken to distil eating patterns in Nepal – should be done, but there is insufficient capacity (GOV); and only scattered efforts on indicators specifically on the degree of the problem of marketing unhealthy foods to children (DR) |
Internal frame alignment | - Some recognition among those involved in the policy process of the importance of NCD prevention (and regulation) rather than just a treatment, but they consider (mistakenly) that the most effective approach is behaviour change (RES, CSO, IO, GOV) - Others considered that structural policies, including marketing restrictions, are the right approach to achieve the most progress, alongside behaviour change (RES, CSO) |
External frame resonance | - Framing marketing restrictions as an issue of child rights could have the power to convert to action / draw the government’s attention (2 RES, 2 MED, CSO) - Public consider taste and quality of high salt noodles to be more important than health concerns, a view shared by Nepalese industry (GOV) |
Strategic capacities | - Evidence of engagement of stakeholders in policy-making, such as through consultation in MAP development (GOV), and facilitating solutions via engaging communities and industry by other key governmental departments or regulators such as the Department of Food Technology and Quality Control via subcommittees (2 GOV) - Lack of strategic capacity indicated: when the MAP was being developed given no one briefed the Chief Secretary and the Prime Minister’s Office on what was expected from them to enable implementation (RES); the government needing to convince the relevant stakeholders – media, advertisement association, and Nepal Press Council – that advertisements are not just for money generation, but also for awareness creation (MED) |
Financial resources | - Insufficient funds (DR, CSO), with money from the tobacco tax not being spent on NCD prevention, but only on treatment (CSO) - Government’s expenditure on NCDs in the health budget is too low (< 6%) (RES), and it should go up; should spend funds from alcohol, tobacco, and other taxes on NCDs (IO) - Ministry of Finance needs to be engaged to ensure sufficient resources (IO, RES) - May be fiscal space for policy development in the future (IO) |
Private sector interference
“If we initiate making policy on junk food then manufacturers will try to influence it. They will first try influencing at political level. This has happened in case of tobacco…but they could not succeed as our political commitment on tobacco is high”. (Interview 8, GOV)
“government came up with a policy that unhealthy snacks … should not be allowed in the school premises. Two or three weeks later all those big industries people went to the government and said it is not that bad and also influenced government by explaining about their social contributions. The policy was not taken back officially but was not implemented either”. (Interview 16, RES)
“If some mandatory regulations are imposed all of a sudden, it won’t work. It must be self-regulatory”.(Interview 5, PS)
“Media is a medium to provide information and … guide society. Advertisements are not only for making profits, these can also be medium for raising awareness. Monitoring of advertisements is a must and advertisement board is very much necessary in the country [to] … regulate the kind of advertisements broadcasted to children as well as other population”. (Interview 18, MED)
International actor support
“As we have already signed [Framework Convention on Tobacco Control] so to control tobacco is one of the top priorities. But there is no such type of treaty in the junk food/processed food, so government is not compelled to focus on these areas”. (Interview 8, GOV)
“there are partners, international organisation interested to invest in the control and prevention of NCDs but until and unless the government puts this in the priority agenda nobody is going to come up”.(Interview 17, CSO)
Legislative, regulatory and policy frameworks
“serious planning … and a good sum of budget … allocated for its operation”.(Interview 9, GOV)
“There has been some mass media campaigns on diet and reduction of consumption of salt, sugar and transfat. Nothing else … has been done”. (Interview 1, GOV)
Political administration support
“[the] state may feel the top-most priority in present situation is federal restructuring”.(Interview 18, MED)
“if we invest in the prevention now means we can see the outcome in the future after a long time, but if they invest in … immediate treatment … they get the popularity”.(Interview 4, GOV)
“this government [has a] … majority and this is one of the strongest … government [s] … if the government wants … they can really enforce … regulation”. (Interview 12, IO)
Evidence
“it’s not that government does not know. But there are still communicable diseases … to be tackled”.(Interview 10, IO)
“I feel Nepal Health Research Council was not able to convince/drive policy makers … for taking concrete actions based on the … [NCD Risk Factors] STEPS survey”.(Interview 9, GOV)
“really don’t want to see any evidence from outside … They always ask for local evidences … whether even the local evidence are used properly”.(Interview 11, RES)
“These things have … been proved by experience of other countries where it has been implemented. Restricting these things in the community through policy is effective”.(Interview 17, CSO)
Organisational capacities
“don’t have capacity to regulate [international and online media]”.(Interview 18, MED)
“should choose the right person...The government brings people from outside who are not aware of the local realities. The … consultant comes and does his job and the thing doesn’t move forward … as … there is no local ownership. Be it abortion, be it women’s health, be it smoking, everything was done by us” (where respondent was reporting on successfully implemented health interventions).(Interview 16, RES)
“they’re trying to get benefit of the technical people being involved in the policy and guidelines level thing, so maybe things can be different now”.(Interview 11, RES)
Discussion
Power as decision-making: the role of civil society and multi-stakeholder coalitions in achieving policy change
Power as non-decision making: role of private sector interference in inhibiting policy consideration
Ideological power: role of norms and narratives in inhibiting policy alternatives
Limitations
Conclusion
Based on the findings from our interviews and wider understanding of the literature on policy change, we have identified five areas where strategic action is needed to generate political incentives to promote the development, adoption and implementation of effective policies to restrict marketing of unhealthy food to children. 1. Build a multi-stakeholder coalition. Nutrition advocates, researchers and civil society, should develop a multi-stakeholder coalition to generate political incentives to put and keep marketing restrictions on the political agenda, and counter private sector interference. Nepal has a strong history of Government and civil society collaboration on tobacco (an area in which Nepal has shown policy leadership [53]), and it already has a base of support, such as via the Nepal NCD Alliance and Nepal Heart Foundation. Nepal has also experienced NCD policy success when the policy community (e.g. government, international organisations, research institutions and clinicians) cohesively advocated for evidence informed, NCD policy formation, including in implementing alcohol restrictions and the Multi-sector Nutrition Plan. Civil society mobilisation has also been a key factor in overcoming food industry interference or generating government commitment [41] for marketing restrictions in other countries, via communications networks and media [54], providing technical and financial capacity, or acting as “knowledge brokers” [43, 55]. 2. Reframe the challenge and use local evidence. A multi-stakeholder coalition could raise the importance of marketing restrictions by: a. Framing the challenge (unhealthy food marketing) and solution (marketing restrictions) as protecting child rights to justify government intervention to combat recently introduced but increasingly dominant norms and narratives. The child rights frame was suggested by respondents to have the power to draw the government’s attention and get it to convert words into robust regulatory action. A child rights frame has been advocated for globally to help build political will as child rights are often a government priority [56]. As child rights are enshrined in Nepal’s constitution [57] any regulation of marketing of unhealthy food to children in Nepal could rely on these rights [58] and leverage human rights monitoring mechanisms [55]. b. Leveraging existing evidence to show that now is the time to restrict marketing, including evidence of Nepal’s growing NCD burden and of the population’s increased access to unhealthy foods. International evidence of the need for and effectiveness of marketing restrictions, including the most effective form of regulation, is likely to be applicable, and was successfully applied in Chile alongside local evidence [56]. Existing tools could also be used, such as the South-East Asian WHO Region’s Nutrient Profiling Model [59] to provide objective criteria for unhealthy food marketing and ensure proportionate regulations [43, 60]. However, advocates will need to support the generation of new evidence to help design effective marketing restrictions (e.g. to better understand the exposure and power of marketing to children in Nepal). 3. Adopt a whole of government approach. The above two actions would help to build political support across the ministries required to develop and implement restrictions on marketing of unhealthy food to children, from the Ministry of Communication and Information Technology to the Ministry of Finance. Brazil’s experience (where the Attorney General suspended a proposal to restrict marketing supported by the ministry of health) suggests whole-of-government support is required [61]. This mirrors experiences in LMICs, where inadequate political administrative support was a barrier to implementation due to governments’ resistance to the hard policy tool of regulating, concern about trade threats, or viewing restrictions as contrary to economic development [41, 47, 55, 62]. 4. Appoint a lead institution. An institution with a broad remit should be charged with overseeing policy development and implementation of restrictions via an interagency mechanism. In contrast to the Ministry of Health, the National Planning Commission, with proven experience in multi-sectoral policy execution and high standing among Ministries could more ably deal with the complexity of regulating cross-border marketing, coordinate multi-sectoral action, address competing and norms and narratives, and counter private sector interference. The importance of a strong lead institution was supported by Nepali respondents as well as experience in Thailand where lead agencies needed sufficient authority to operate effectively to implement marketing restrictions [45]. A strong lead institution may also safeguard against any leadership vacuum created by high ministerial turnover, and ensure stronger implementation capacity, including adequate funding and human resources to govern marketing restrictions (reported by respondents and in the literature [63, 64]). 5. International support. The above agenda would arguably be aided by: a. A strong international mandate or code for unhealthy food marketing to children (or extension to the International Code of Marketing of Breastmilk Substitutes) - which the Framework Convention on Tobacco Control provided to national tobacco control efforts - has been called for by academics since 2011 [65‐67] In 2019, experts also called on the WHO Director-General and the UN High Commissioner for Human Rights to develop human rights guidelines on healthy diets, which included a focus on marketing of unhealthy foods to children [68]. b. In the absence of a global code, greater international financial and technical support for Nepal, including for regional coordination, is needed. It is clear from respondents, and literature from Nepal, the South-East Asian WHO Region, and LMICs that current support is insufficient, including research funding for NCD prevention and control [12, 43, 69, 70]. Such support is a key assumption in Nepal’s MAP [37]. The importance of it has been demonstrated in Mexico which collaborated with the Pan American Health Organization’s task force to control food marketing to children and adolescents [54], and in Fiji, where the WHO provided legal and health expertise to ‘build momentum’ to advance a bill seeking to restrict marketing of unhealthy foods to children [60]. |