Inclusion of “best buy” interventions
Among the twelve documents that were reviewed, only three included at least one “best buy” intervention and this was mainly on restricted access to retailed alcohol (See Table
3). The three documents are: the Liquor Act, of 1979 (Last Amended in 2000) Chapter 50:07 of the Laws of Malawi, the 2015 Liquor Production, Marketing & Distribution Regulations, and the National Alcohol Policy (2017). None of the policy documents included “best buy” interventions related to increased taxation and ban on advertising.
Table 3
Inclusion of WHO “Best Buys” in Alcohol Policies in Malawi
Liquor Act, of 1979 (Last Amended in 2000) Chapter 50:07 of the Laws of Malawi | 1979 (amended in 2001) | Local Government | Yes | No | No |
Liquor (Production, Marketing & Distribution) Regulations | 2015 | Industry and Trade | Yes | No | No |
The National Alcohol Policy | 2015–2017 | Health | Yes | Partial | Partial |
All documents included other interventions outside the “best buys”, some of which are among the ten global policy options meant to control and reduce harmful use of alcohol [
6]. The other globally recommended interventions identified during document reviews were: counter measures against drunk-driving, promotion of awareness of alcohol related harm and health system response with interventions targeting individuals who are at risk or already affected by harmful use of alcohol.
Rationale and objectives of the current alcohol policies
Malawi’s Liquor Act, of 1979 [
16] was developed to give powers to local governments to regulate the manufacture and sale of intoxicating liquor by granting permits/licenses to businesses intending to manufacture or sell beer and other alcoholic beverages. The Liquor Act covers restricted access to retailed alcohol by stipulating the permitted hours for the sale of liquor by permit holders who are approved by the Local Government. The Act also restricts the supply of opaque and traditional beer to young people by stipulating that “opaque or traditional beer shall not be supplied to persons under the age of 18 years” [
16].
The 2015 Liquor Production, Marketing & Distribution Regulations [
17] were developed to prohibit the manufacturing and importation of liquor packaged in plastics or polythene bags as well as the packaging of industrial grade ethanol for purposes of consumption. The regulations are also aimed at regulating the quantities and packaging standards of alcoholic beverages. The regulations intend to control the availability of cheap liquor to prevent people from consuming harmful quantities of liquor in Malawi. The regulations address the “best buy” interventions by imposing restrictive standards on production and packaging about the type of liquor, volume and package materials used.
The National Alcohol Policy was in final draft form (Cabinet Paper level) at the time of document analysis but was later approved by cabinet in January 2017 [
18]. It is an overarching policy for controlling harmful use of alcohol in Malawi. It provides comprehensive mechanism for development, implementation, coordination, monitoring and evaluation of health, social and economic interventions related to harmful alcohol consumption in Malawi [
18]. The main policy objective is to reduce the health and socioeconomic burden associated with harmful use of alcohol through strategies that include: ensuring effective regulation of availability and accessibility of commercial alcoholic products (including informally produced alcoholic products), promoting health and other sectors’ response to harmful use of alcohol, ensuring reduction in demand for alcoholic products through behavior change related interventions, and promotion of monitoring, surveillance and research on harmful use of alcohol. The policy advocates for regulation of tax for alcoholic products based on percentage of alcohol volume, albeit it does not indicate the tax increase schedule to be adopted. The policy further states regulation of advertising and marketing of alcoholic drinks as one of priority intervention areas. However, the policy implementation strategy does not include a total ban of alcohol advertising.
In the following section, we explore the formulation process and use of MSA for the National Alcohol Policy. We focus on the National Alcohol Policy because it was the most recently formulated policy(hence reducing possibilities of recall bias) but also because through its initial development processes, Malawi was previously hailed as a best practice in alcohol policy formulation [
19].
The first step for establishing an alcohol policy in Malawi was initiated in 2006 by the alcohol industry. Several NGOs including Drug Fight Malawi, that were invited to the initial industry facilitated consultative meeting noted, with concern, that the aim of the policy was to encourage responsible drinking and that alcohol industry led policy had limited scope. There was also an absence of representation from government ministries responsible for alcohol harm control. As such, these NGOs abandoned the industry-led policy. By 2007, with support from a Norwegian-based international development organization, For Utvitling/Development (FORUT), Drug Fight Malawi initiated a new national policy formulation process with involvement of Malawi Government authorities and other stakeholders. National level consultation process for a comprehensive national alcohol policy started in 2008 [
19].
By 2009, a multi-sectoral National Task Force was formed to develop the National Alcohol policy. The task force included relevant ministries and departments such as Ministry of Home Affairs and Internal Security, Ministry of Health, Ministry of Education, Ministry of Trade and Industry, Ministry of Youth, Ministry of Local Government, Ministry of Gender, Ministry of Information, Ministry of Justice, Malawi Police Service, National Youth Council; and members from various NGOs and Civil Society organizations. In line with WHO Global Alcohol Strategy [
6], the alcohol industry was notably not included in the National Task Force. The National Task Force conducted consultative meetings in eight representative districts with local stakeholders including traditional leaders, religious leaders, local NGOs and the public. Apart from the National Task Force, a consultant was hired by FORUT to help with the zero-drafting of the policy. The drafts were reviewed by the task force in a series of meetings.
By June 2011, a national stakeholders’ meeting was held to validate the draft national alcohol policy. Among the attendees of the stakeholders’ meeting were representatives of the alcohol industry who formally raised concerns regarding their exclusion from the formulation process and that the awareness promotion component of the draft policy was weak because responsible drinking was not covered. This necessitated further review of the draft alcohol policy by the National Task Force, led by the NCD and Mental Health Unit of the Ministry of Health that had been nominated to take over coordination and finalisation of the policy.
The revised (pre-final draft) national alcohol policy had addressed some issues raised by the alcohol industry. However, after presenting it to the health sector Essential Health Package Technical Working Group (TWG) on 6th February 2013 [National NCD Program Manager, MOH, 2015], the TWG recommended that the responses to the concerns by the alcohol industry be presented to the alcohol industry representatives. Thus, on 7th March 2013, a formal consultative dialogue involving the Ministry of Health, members of the NTF and representatives of the alcohol industry was held [National NCD Program Manager, MOH, 2015].
Between mid-2013 and end-2014, the draft NAP underwent endorsement processes by the Senior Management Team at the Ministry of Health, inter-ministerial Principal Secretary’s committee, the Parliamentary Committee on Health and the Cabinet Committee on Social and Health. All these committees made inputs that were taken into consideration in finalising the National Alcohol Policy and writing a cabinet paper that was submitted to the full Cabinet in August 2016. Eventually, the National Alcohol Policy for Malawi was adopted in January 2017, eight years after the first national consultations.
Data from key informant interviews and a review of the national alcohol policy show that actors from several sectors were involved in its formulation. The extent of MSA was high since there were more than ten sectors involved. The sectors and their actors as well as their specific roles are presented in Table
4. The Government, through the Ministry of Health and the Ministry of Home Affairs had participated extensively in the formulation process. Similarly, CSOs and WHO had a significant level of involvement through financial and technical support to the process. Other members of the National Task Force participated in the meetings around formulation and are expected to lead in the implementation.
Table 4
Actors’ involvement and their roles
Health | Ministry of Health | Government | Leading role in the development and implementation. Coordination of the process through the NCDs unit |
Drug Fight Malawi | CSO/Local NGO | Financial and technical support |
Malawi Alcohol Policy Alliance | CSO/Local NGO | Advocacy support |
JournAIDS | CSO/Local NGO | |
World Health Organisation (Malawi Office) | International Organisation | Technical support |
FORUT | International Organization | Financial and technical support |
Law enforcement | Ministry of Home Affairs | Government | Initially led the formulation of the alcohol policy (2009–2011). Actively participated throughout the formulation and acts as a key enforcement agency |
Malawi Police Services | Government | Stakeholders involved as part of National Task Force during the formulation process. Actively participated in writing and review meetings |
Industry and Trade | Ministry of Industry and Trade | Government | Stakeholders involved as part of National Task Force during the formulation process. Actively participated in writing and review meetings |
Alcohol industry | Private | |
Communication/Information | Ministry of Information | Government | |
Electronic and Print Media Houses | Media | |
Parastatals | National Youth Council | | |
Malawi Bureau of Standards | | |
Other ministries | Office of the President and Cabinet | Government | Stakeholders involved as part of National Task Force during the formulation process. Actively participated in writing and review meetings |
Other ministries | Ministry of Local Government | Government |
Other ministries | Ministry of Gender and Community Services | Government |
Justice | Ministry of Justice | Government |
Education | Ministry of Education | Government |
Other ministries | Ministry of Youth | Government |
Professional Association | Teachers Union of Malawi | CSO/Local NGO | Stakeholders involved as part of National Task Force during the formulation process. Actively participated in writing and review meetings |
Academic/Research | Centre for Social Research, University of Malawi | Academic/Research | Evidence generation through Alcohol studies |
Facilitators for use of MSA in alcohol policy formulation
Several factors were identified as having facilitated use of MSA in the National Alcohol Policy formulation process. Firstly, government ministries led the formulation process which ensured that the policy was a national issue and hence improved participation of different sectors. From 2009 to 2011, the initial consultation and formulation process was led by the Ministry of Home Affairs and Internal Security with support from Drug Fight Malawi. From 2011, the Ministry of Health, through the Non-Communicable Diseases and Mental Health Unit, took over the coordination role in the National Alcohol Policy formulation process. Apart from the government leadership role, civil society support also facilitated the formulation process. Drug Fight Malawi, with funding from FORUT, was instrumental in the formulation of the Malawi National Alcohol Policy through financial support for consultative meetings, facilitation of meetings, technical support and advocacy. The formulation process was also supported by the WHO through provision of technical support.
Secondly, there was a National Task Force which included stakeholders who had a shared common understanding of the burden of harmful use of alcohol. Each of the stakeholders felt there was a need to formulate this policy.
“I think basically we all saw that we had a common interest in terms of how the ministry of health presented the problem. Everyone saw that it was a serious issue [for example] how alcohol was being abused by children. So, the main reason was that everyone saw that this is serious. [They thought] let’s tackle this issue [and] develop a policy and after that maybe we can have a regulatory framework and some laws. So, the biggest factor was simply the seriousness of the problem.” (Industry Officer, Ministry of Industry and Trade)
While all stakeholders were keen on developing an alcohol policy, their rationale was different. This was based on their varied perceptions of problems caused by harmful use of alcohol. The perceived problems included: negative impact on education especially among young people, road traffic accidents, increasing cases of gender based violence and increasing prevalence of NCDs.
Regular update meetings and communication among the stakeholders was also highlighted as a key factor for MSA in the formulation of the alcohol policy. This was made possible with limited funding.
“There was back and forth communication between the regional office and the country office, and the other stakeholders at the national level, providing advice as to what extent we can we involve the [alcohol] industry. So those were some of the key guiding [principles]… [We used] those guidelines to make sure that the process of developing the policy was meeting the public health objectives that it was intended for.” (Health Promotion Officer, International NGO)
Barriers for use of MSA in policy formulation
Key informants identified several challenges in involving different stakeholders in the formulation of the alcohol policy. The first challenge to involving several sectors was funding. There was limited funding to involve different stakeholders in meetings and workshops for the formulation of the alcohol policy in Malawi.
“I think costs for conducting meetings. The NCD unit sometimes did not have the funding, probably that also could be the reason why they couldn’t have so many people.” (Nutrition Officer, Ministry of Health)
“Well I think one of the challenges is resources to try and get opinions of different stakeholders on board” (Health Project Coordinator, International NGO)
The second barrier was high staff turnover rates through transfers within and between departments/ministries, resignations and/or retirement. Some sectors were represented by different people at different meetings and workshops. In some cases, there was no proper handover of what was to be discussed at subsequent meetings.
“The major challenge was coordination. If you are having different sectors, the first thing is it’s not possible to have consistent participation of the members. So, you keep on having new members coming in [because] some members have been transferred. Some sectors like education, some NGOs and (…) civil societies like Teachers Association of Malawi would have permanent members. Sectors like home affairs still have the same people who have been in the process from that beginning to the present, but other sectors like Ministry of Trade would have a senior person coming [for one meeting] and then a junior person coming in [for a subsequent meeting]. That, sometimes caused problems.” (Health Promotion Officer, International NGO)
The third barrier was coordinating the different sectors and getting their views and interests on board. The variety of sectors meant that some of their views were very different and it was difficult to include all of them on board. Differences in views and interests among sectors was also a source of conflict in the formulation of the alcohol policy. Initially, there was competition as to who would lead the process between the Ministry of Health and the Ministry of Trade and Industry. There was also conflict due to differences in mandates and objectives. While the Ministry of Health emphasized the public health effects of alcohol, the Ministry of Trade and Industry was also interested in alcohol as a source of revenue and economic development of the country.
The fourth barrier to MSA was interference by the alcohol industry. Initially, the alcohol industry had initiated an alcohol policy process based on self-regulation. Even after the NGOs abandoned the initial process and alerted government on the need for a national alcohol policy that is independent of alcohol industry interests, the industry still took part in some of the discussions on the formulation of the alcohol policy through dialogue sessions. During these meetings, alcohol industry representatives were reported to have facts that countered what government and NGOs were presenting, specifically highlighting that alcohol is not as harmful as the NGOs were stating. Some key informants also suggested that the alcohol industry was reported to have approached some members involved in the alcohol policy formulation to influence them to support the views and perspectives of the industry.
“When you look at the alcohol industry, the way I’ve seen them behaving is that they will make direct contact with those who are trying to formulate a policy or the different key ministries that are stakeholders. They will also approach the ministers and give them a reason why alcohol is important to Malawi. They give very convincing reasons [for example], taxes [from sale of alcohol] and their effects on the budget. But they don’t really talk about the health and social impact of alcohol. They go to influential leaders of the society to try and get them on their side and maybe to try and reduce the progress of the alcohol policy rolling out. That’s one of the things they do.” (Health Project Coordinator, International NGO)
Despite the barriers, Malawi achieved a multi-sectoral process to National Alcohol Policy formulation. The policy stipulates similar coordinated efforts that have been planned through establishment of multiple multi-sectoral structures at every implementation level [
18]. However, these barriers ought to be mitigated to effectively achieve MSA through the implementation of the National Alcohol Policy.