Analysis of Non-communicable disease prevention policies in five Sub-Saharan African countries: Study protocol

The burden of non-communicable diseases (NCDs) and their risk factors are increasing in sub-Saharan Africa [1‐3]. NCDs account for 63 % of mortality globally and the 80 % of NCD-related deaths that occur in low and middle income countries [4, 5]. Current projections indicate that by 2020, the largest increase in NCD-related deaths will occur in Africa and by 2030, NCD-related deaths will exceed (by 75 %) the combined deaths from communicable diseases, nutritional, maternal and neo-natal deaths [6]. Out of the many NCDs, four – cardiovascular diseases, diabetes, cancers and chronic respiratory illnesses – have been identified as being responsible for the majority (75 %) of all NCD-related mortality [3]. These four NCDs also share a set of four risk factors: tobacco use, unhealthy diet, harmful alcohol use and physical inactivity. These factors have been linked to increase in preventable morbidity and disability in the region, and globally currently causing over 36 million deaths annually. More than 9 million (a quarter) of these deaths occur before the age of 60 years [6‐8].

To address the burden of NCDs and their associated risk factors, the World Health Organization (WHO) has advocated for a ‘whole-of-government’ approach in its most recent global strategy for NCD prevention and control [9]. A whole-of-government approach denotes public service agencies working across portfolio boundaries to achieve a shared goal and an integrated government response to particular issues. Furthermore, the global NCD strategy recommends that such the whole-of-government approach should be aimed at addressing the social determinants of health. The social determinants of health are those conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life [10]. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems. Social determinants of health play a great role in creating the environment that influences population risk and individual behavior. These determinants lie beyond the purview of the health sector and several non-health sectors (e.g., agriculture, education, urban planning, and transportation) play a big role in shaping the NCD environment. A key component of the whole-of-government approach is the multi-sectoral approach (MSA). MSA in the context of health refers to actions undertaken by sectors outside the health sector, possibly, but not necessarily, in collaboration with the health sector, on health or health- related outcomes or the determinants of health or health equity [11]. As such, action within and between sectors, at the local, regional, provincial, national, and global levels, is needed to influence the social and economic landscape that enables the health and well-being of the population. Thus successful NCD prevention therefore needs MSA to address factors that impact on the physical, social and political environment that shapes individual choices.

The first Global Ministerial Conference on Healthy Lifestyles and Non Communicable Disease Control held in Moscow in April 2011 set the stage for the high level UN-Summit on NCD in New York and the subsequent political declaration in September 2011 [6]. The Moscow Declaration on NCDs that emanated from the ministerial conference contained a commitment from governments to develop multi-sectoral public policies that create equitable health promoting environments that enable individuals, families and communities to make healthy choices, lead healthy lives as they give priority to NCD prevention and control, ensuring complementarity with other health objectives and to strengthen the engagement of other sectors [8]. With this regard, governments pledged to promote, establish or strengthen, and implement by 2013, multi-sectoral national policies and plans for the prevention and control of NCDs, taking into account the WHO 2008–2013 Action Plan for the Prevention and Control of NCDs. This plan identifies MSA as a cornerstone for NCD prevention at population level. It also identifies several “best buys” for NCD prevention including measures to reduce the four common risk factors of tobacco use, unhealthy diet, physical inactivity and the harmful use of alcohol that would deliver the greatest benefit in reducing population level risks in a cost-effective manner [12]. Table 1 provides examples of the NCD prevention “best buys.” It is evident that the implementation of these “best buys” requires MSA. For example, raising taxes and enforcing advertising bans/restrictions on tobacco and alcohol will require the involvement of ministries of finance, health, information, as well as the legislative arms of government, law enforcement, and the media.

Evidence exists on successful MSA in tobacco control initiatives in several settings [11, 13]. However, there is limited research on the application and success of MSA for the control of other risk factors (i.e., harmful use of alcohol, physical inactivity and unhealthy diets) in sub-Saharan Africa. Evidence also exists on the use of MSA in improving population level health outcomes. A systematic review of multi-sectoral interventions to address social determinants of health while improving health equity was recently conducted [13]. In general, the review found that there were successful examples of MSA that resulted in health impacts, but it had substantial limitations in that most interventions did not specifically address the social determinants of health, most only included developed countries, they focused on interventions in specific settings, such as schools, they provided little detail about process, and they often did not articulate how relationships between sectors contributed to outcomes.

This paper describes, “Analysis for Non-communicable Disease Prevention Policies in Africa (ANPPA),” a research project that aims to fill the gaps highlighted by the systematic review above. The main contribution of this research will be the generation of evidence on MSA in low-income settings in the sub-Saharan Africa region. In addition, the research will provide a deeper understanding of the processes through which MSA is actualized, including the challenges, constraints and enabling factors.

The immediate main goal of ANPPA is to generate evidence on the extent to which and how MSA informs policies related to the implementation of NCD prevention “best buys” in six countries in sub-Saharan Africa: Kenya, Malawi, Nigeria, Cameroon, Togo and South Africa. The evidence generated will catalyze a process of policy engagement by the established network of researchers to support efforts to adopt MSA into policy making and programming.

The specific objectives of ANPPA are (1) To conduct an in-depth assessment in each country about the state of implementation of the NCD “best buys” and of the barriers to their full implementation; (2) To generate robust evidence on the extent to which and how multi-sectoral action is used in the formulation of policies for the implementation of the NCD “best buys” in different contexts, with an emphasis on the population-based interventions; and (4) To build research capacity on multi-sectoral action for health in the region and to set up a networked group of researchers in this area to monitor and assess the effectiveness and impact of multi-sectoral approaches in the long term, and (4) To provide robust evidence to policy and decision-makers in each country to inform the design and implementation of the NCD “best buys”. Ultimately, it is hoped that the evidence generated through ANPPA will be used to promote and adopt multi-sectoral approaches to policy-making for NCD prevention and control in sub-Saharan Africa.

We use two frameworks to guide ANPPA: The Walt and Gilson framework of policy analysis [14] and the McQueen analytical framework for inter-sectoral action [15]. The Walt and Gilson framework acknowledges the non-linearity of the policy process as well as the incremental nature of policy making. In this framework, Walt and Gilson focus on four factors: i) The policy contents, ii) the policy actors, iii) the policy processes, and iv) the policy context [14]. The content of particular policies may be examined by looking at the policy objectives, the way the policy is designed, whether there is an accompanying implementation plan and specific mechanisms through which the policy should be actualized. The policy actors will be examined by looking at who was involved in the policy processes, their roles and who else ought to have been involved. The processes include the different stages of the policy making process and the strategies employed to involve different actors. The context may include changes in political climate and management structures; socio-cultural, economic or technological changes; changes in the global financial situation; and conflicting development agendas between governments and development partners.

The framework by McQueen and others is useful in examining the policy processes [15]. The framework focuses on the role of governance in tackling the social determinants of health through the emerging policy practice of “Health in All Policies” that is central to the envisaged NCD prevention efforts. Health-in-all-policies is an approach to public policies across sectors that takes into account the health implications of decisions, seeks synergies, and avoids harmful health impacts in order to improve population health and health equity [16]. The framework by McQueen describes several inter-sectoral governance structures and actions taken by these structures in promoting Health-in-All-Policies. The governance structures include those at central government level (ministerial linkages, cabinet committees and secretariats); parliament level (parliamentary committees); civil service level (interdepartmental committees and units, mega-ministries and mergers); funding arrangements (joint-budgeting, delegated financing) and mechanisms for engagement beyond government with the public, civil society and industry. Depending on the policy, these governance structures may play different roles to initiate or facilitate a policy process and its implementation. These actions include evidence support, setting goals and targets, coordination, advocacy, monitoring and evaluation, policy guidance, financial support, providing legal mandate and actual implementation and management [15].

We have described the ANPPA study, which aims to generate evidence on the extent to which and how MSA informs policies related to the implementation of NCD prevention “best buys” in six countries in sub-Saharan Africa: Kenya, Malawi, Nigeria, Cameroon, Togo and South Africa. This study builds on the WHO’s recommended ‘whole-of-government’ approach and MSA for development and implementation of national policies and plans for the prevention and control of NCDs [8, 9]. A unique facet of this study is its multiple case study approach that incorporates case studies both across six sub-Saharan African countries and across multiple “best buys” for addressing NCDs (strategies to reduce tobacco use, unhealthy diet, physical inactivity and the harmful use of alcohol).

The ANPPA study will improve our understanding of the WHO’s recommended approach of MSA by specifically seeking to understand the processes national governments use to engage relevant stakeholders in the policy development processes, and to assess the impact of MSA on policy outcome. In addition, the research will provide a deeper understanding of the processes through which MSA is actualized, including the challenges, constraints and enabling factors. We expect that countries that engage in MSA may take longer to enact policies because of the time required to ensure shared understanding among all stakeholders of the problems and the solutions, and that those policies may ultimately be more effective in large part due to that shared understanding. This evidence from different country contexts, and across different “best buys” will inform opportunities for other developing countries to better assess their country’s NCD policies and to implement change effectively and in a way that builds off the experiences of the ANPPA study countries.

The ANPPA study will also contribute to the generation of evidence on MSA in low-income settings specifically in the sub-Saharan Africa region. Given current projections that indicate that by 2020, the largest increase in NCD-related deaths will occur in Africa and by 2030, NCD-related deaths will have exceeded (by 75 %) the combined deaths from communicable diseases, nutritional, maternal and neo-natal deaths [6], this region is particularly appropriate for this study. The process of systematically assessing each country’s NCD-related policies and informing relevant stakeholders to create change will have immediate impact in these countries. Being able to provide lessons learned to other sub-Saharan African countries will also be highly useful.

A few challenges have been identified in the initial implementation of the study. This includes inability to get electronic or hard copies of some of the policy documents, numerous rescheduling of meetings by the key informants, refusals and/or reluctance by some key informants to participate in the study and finally some of the selected key informants required additional approvals from their sector heads before participating in the interviews. By appropriately adjusting to these challenges and limitations, findings from the ANPPA study will not be significantly compromised.

Finally, by illustrating the association between MSA to implement NCD policies and the health status of countries’ citizens, local, regional, and national policy makers, as well as other appointed and elected government officials, non-governmental organizations, and industry stakeholders may find utility to the research findings and conclusions of the ANPPA study. Engagement of policy makers and other stakeholders will ensure future improvements to NCD policies and implementation. Expansion of ANPPA study findings to all interested and influential parties can supplement the potential impact of these findings on a global scale.