Foregrounding women and household dynamics to inform Article 17: a qualitative description analysis of tobacco farming households in Mozambique.

PURPOSE: This paper examines the intrahousehold dynamics between women and men present in tobacco farming households in Mozambique. Attention to the experiences and realities of the smallholder farmers is crucial for understanding approaches to alternative livelihoods. Intrahousehold dynamics can provide important insights into how these households and their members view tobacco production and engage with the political economy of tobacco farming, how they make decisions, and the rationale and values behind these decisions. METHODS: Data were collected through single-gender focus group discussions (n=8) with 108 participants (men=57, women=51). Analysis was informed by a qualitative description methodology. This research presents a gender-based analysis examining the perspectives, roles, decision-making processes and desires of female and male tobacco farmers in four key tobacco-growing districts in Mozambique. FINDINGS: Throughout this paper, women are found to hold leverage and influence in tobacco farming households, and this leverage is in part gained via the necessity of women's unpaid labour in achieving profitability in tobacco farming. Both women and men are also found to strongly desire and pursue the well-being of the household. CONCLUSION: Women hold agency within tobacco-growing households and participate in decision-making processes regarding tobacco agriculture. Women should be included in future tobacco control policies and programmes pertaining to Article 17.

What Generates Attention to Health in Trade Policy-Making? Lessons From Success in Tobacco Control and Access to Medicines: A Qualitative Study of Australia and the (Comprehensive and Progressive) Trans-Pacific Partnership.

BACKGROUND: Despite greater attention to the nexus between trade and investment agreements and their potential impacts on public health, less is known regarding the political and governance conditions that enable or constrain attention to health issues on government trade agendas. Drawing on interviews with key stakeholders in the Australian trade domain, this article provides novel insights from policy actors into the range of factors that can enable or constrain attention to health in trade negotiations. METHODS: A qualitative case study was chosen focused on Australia's participation in the Trans-Pacific Partnership (TPP) negotiations and the domestic agenda-setting processes that shaped the government's negotiating mandate. Process tracing via document analysis of media reporting, parliamentary records and government inquiries identified key events during Australia's participation in the TPP negotiations. Semi-structured interviews were undertaken with 25 key government and non-government policy actors including Federal politicians, public servants, representatives from public interest nongovernment organisations and industry associations, and academic experts. RESULTS: Interviews revealed that domestic concerns for protecting regulatory space for access to generic medicines and tobacco control emerged onto the Australian government's trade agenda. This contrasted with other health issues like alcohol control and nutrition and food systems that did not appear to receive attention. The analysis suggests sixteen key factors that shaped attention to these different health issues, including the strength of exporter interests; extent of political will of Trade and Health Ministers; framing of health issues; support within the major political parties; exogenous influencing events; public support; the strength of available evidence and the presence of existing domestic legislation and international treaties, among others. CONCLUSION: These findings aid understanding of the factors that can enable or constrain attention to health issues on government trade agendas, and offer insights for potential pathways to elevate greater attention to health in future. They provide a suite of conditions that appear to shape attention to health outside the biomedical health domain for further research in the commercial determinants of health.

The Political Economy of Tobacco in Mozambique and Zimbabwe: A Triangulation Mixed Methods Protocol.

Changing global markets have generated a dramatic shift in tobacco consumption from high-income countries (HICs) to low- and middle-income countries (LMICs); by 2030, more than 80% of the disease burden from tobacco use will fall on LMICs. Propelling this shift, opponents of tobacco control have successfully asserted that tobacco is essential to the economic livelihoods of smallholder tobacco farmers and the economy of tobacco-growing countries. This nexus of economic, agricultural and public health policymaking is one of the greatest challenges facing tobacco control efforts, especially in LMICs. To date, there is a lack of comparative, individual level evidence about the actual livelihoods of tobacco-growing farmers and the political economic context driving tobacco production. This comparative evidence is critically important to identify similarities and differences across contexts and to provide local evidence to inform policies and institutional engagement. Our proposed four-year project will examine the economic situation of smallholder farmers in two major tobacco-growing LMICs-Mozambique and Zimbabwe-and the political economy shaping farmers' livelihoods and tobacco control efforts. We will collect and analyze the existing data and policy literature on the political economy of tobacco in these two countries. We will also implement household-level economic surveys of nationally representative samples of farmers. The surveys will be complimented with focus group discussions with farmers across the major tobacco-growing regions. Finally, we will interview key informants in these countries in order to illuminate the policy context in which tobacco production is perpetuated. The team will develop country-level reports and policy briefs that will inform two sets of dissemination workshops in each country with relevant stakeholders. We will also conduct workshops to present our findings to the survey and focus group participants, and other members of these tobacco-growing communities, so they can directly benefit from the research to which they are contributing.

Shifting from tobacco growing to alternatives in Malawi? A qualitative analysis of policy and perspectives.

Tobacco is the primary export commodity in Malawi and an important contributor to foreign earnings. The entrenchment of tobacco interests within government has partly explained why Malawi has lagged in its efforts to address the health consequences of tobacco and has been a vocal opponent of global tobacco control. Despite the extensive historical and entrenched relationship between the economy of Malawi and tobacco production, there have been important shifts at the highest policy levels towards the need to explore diversification in the agricultural sector. There is explicit recognition that alternatives to tobacco production must be pursued. This study provides an analysis of the policies and perspectives that characterize contemporary government approaches to tobacco and alternatives in Malawi by interviewing key government officials working on tobacco policy and reviewing recent policy documents. This research finds that there is openness and movement towards reducing tobacco growing in Malaw, including efforts to reduce tobacco dependency. Rather than a singular tobacco policy discourse in the country, there is a somewhat conflictual set of policies and perspectives on the future of tobacco in Malawi. Informing these policies and perspectives is the interplay between the economics of agricultural production (tobacco vs other crops), global markets (ranging from the ability to generate export earnings to the inability to compete with wealthier countries' non-tobacco crop subsidies) and the lack of developed supply and value chains other than those created by the transnational tobacco industry. The implications for government policy supporting a move away from tobacco dependence are not straightforward: there is a need to fill the supply chain gap for alternative crops, which requires not only strong intersectoral support within the country (and some challenge to the residual pro-tobacco narratives) but also international support.

Understanding Alternatives to Tobacco Production in Kenya: A Qualitative Analysis at the Sub-National Level.

Tobacco is a key cash crop for many farmers in Kenya, although there is a variety of challenges associated with tobacco production. This study seeks to understand alternatives to tobacco production from the perspective of government officials, extension officers, and farmers at the sub-national level (Migori, Busia, and Meru) in Kenya. The study analyzes data from qualitative key-informant interviews with government officials and extension officers (n = 9) and focus group discussions (FGDs) with farmers (n = 5). Data were coded according to pre-identified categories derived from the research aim, namely, opportunities and challenges of tobacco farming and alternative crops, as well findings that illustrate the policy environment that shapes the agricultural context in these regions. We highlight important factors associated with the production of non-tobacco agricultural commodities, including the factors that shape the ability of these non-agricultural commodities to serve as viable alternatives to tobacco. The results highlight the effect that several factors, including access to capital, markets, and governmental assistance, have on farmer decisions. The results additionally display the structured policy approaches that are being promoted in governmental offices towards agricultural production, as well as the institutional shortcomings that inhibit their implementation at the sub-national level.

Explaining Why Farmers Grow Tobacco: Evidence From Malawi, Kenya, and Zambia.

INTRODUCTION: Tobacco production continues to increase in low- and middle-income countries creating complications for tobacco control efforts. There is the need to understand and address the global tobacco leaf supply as a means of decreasing tobacco consumption and improving farmers livelihoods in line with Article 17 of the WHO Framework Convention on Tobacco Control. This study aims to understand the reasons why farmers grow tobacco and identify factors that influence these reasons. METHODS: Primary survey data (N = 1770) collected in Kenya, Malawi, and Zambia in the 2013-2014 farming season. Data analysis uses both descriptive and multinomial logistical regression methods. RESULTS: Majority of farmers started and are currently growing tobacco because they believed it was the only economically viable crop. Compared with Malawi, farmers in Kenya and Zambia have a 0.2 and 0.4 lower probability of growing tobacco, respectively because they perceive it as the only economically viable crop, but a 0.04 and 0.2 higher probability of growing tobacco, respectively because they believe it is highly lucrative. There are district/county differences in the reasons provided with some districts having a majority of the farmers citing the existence of a ready market or incentives from the tobacco industry. Statistically significant factors influencing these reasons are the educational level and age of the household head, land allocated to tobacco and debts. CONCLUSION: There is the need to address the unique features of each district to increase successful uptake of alternative livelihoods. One consistent finding is that farmers' perceived economic viability contributes to tobacco growing. IMPLICATIONS: This study finds that perceived economic viability of tobacco is the dominant factor in the decisions to grow tobacco by smallholder farmers in Malawi, Kenya, and Zambia. There is the need to more deeply understand what contributes to farmers' perceived viability of a crop. Understanding and addressing these factors may increase the successful uptake of alternative livelihoods to tobacco. Furthermore, this study demonstrates that a one-size fits all alternative livelihood intervention is less likely to be effective as each district has unique features affecting farmers' decisions on growing tobacco.

Correction to: Consequences of policy incoherence: how Zambia's post-FCTC investment policy stimulated tobacco production.

The paper "Consequences of policy incoherence: how Zambia's post-FCTC investment policy stimulated tobacco production" was published without including the acknowledgements.

Consequences of policy incoherence: how Zambia's post-FCTC investment policy stimulated tobacco production.

Zambia, a tobacco-growing country, provides manufacturing incentives to attract foreign and domestic investment. In an earlier study, we cautioned that these incentives could lead to local tobacco manufacturing, undermining its domestic tobacco control efforts. In 2018, as part of our continuing research program, we conducted key informant interviews (n = 15) and document analyses. Our early caution proved correct. In 2018, taking advantage of tax incentives, British American Tobacco Zambia and Roland Imperial Tobacco opened new cigarette-manufacturing facilities in the Lusaka Multi-Facility Economic Zone. They report capability of producing 25 million cigarettes daily, between 3 and 5 million of which is intended for the domestic market. Zambia's tax incentives for cigarette manufacturing are likely to increase domestic consumption. The 170 new jobs created in the two plants pale when considering long-term health impacts and lost economic productivity of an increase in supply of locally produced cigarette brands.

The Economic Geography of Kenyan Tobacco Farmers' Livelihood Decisions.

INTRODUCTION: The narrative of prosperous economic livelihood of tobacco farmers in Kenya as alleged by the tobacco industry deserves challenge as evidence increasingly suggests that smallholder tobacco farmers are making little or no profits. Article 17 of the World Health Organization Framework Convention on Tobacco Control encourages viable alternative livelihoods for tobacco farmers. There is little evidence, however, on how tobacco farmers make livelihood choice decisions. METHODS: A total of 527 purposefully selected smallholder tobacco farmers in Kenya from three main tobacco-growing regions participated in a 2017 economic livelihood survey. Geo-economic data were matched to surveyed farmers' Global Positioning System coordinates to estimate each farmer's access to nearby economic centers. Ownership of cell phones or radios was also used to estimate farmers' virtual access to nearby economic activities to understand better the role of information. Multivariate logistic regressions were used to control socioeconomic status and self-reported activity in nearby economic centers. RESULTS: Tobacco farmers rarely live within 10 km of an economic center. Results suggest that the further away farmers live from economic centers, the less likely they are to grow tobacco, but more likely to grow tobacco under contract. Also, farmers owning a cell phone or radio are not only less likely to grow tobacco, but also to not engage in farming under contract if they do grow tobacco. CONCLUSIONS: Physical and virtual access to nearby economic activities is significantly associated with tobacco farmers' livelihood choice decision and should be taken into consideration by decision makers while developing interventions for FCTC Article 17. IMPLICATIONS: Smallholder tobacco farmers in lower-income countries are making little or no profits, but few studies have been conducted to illuminate what perpetuates tobacco production, with such studies urgently needed to support governments to develop viable alternative livelihoods for tobacco farmers. This study suggests that geographic and technological factors that shape farmers' economic decisions can help policy makers tailor alternative livelihood policies to different regional contexts and should be a focus of future research in this area.

A gender analysis of a national community health workers program: A case study of Afghanistan.

Gender equity can be a neglected issue in health system reforms. This paper explores the multiple layered gender dynamics of the Afghan Community Health Worker (CHW) Program within broader health system reforms in Afghanistan using a qualitative research design. We interviewed policy makers, health managers, CHWs and community members in 16 sites in 2013 and 2014. We found that gendered societal norms interact and influence the Afghan CHW program in a dynamic way. Gendered social norms around the division of labour tend to privilege women in terms of access to resources at the community level, but it is men who hold leadership positions that ultimately decide how the resources are to be distributed. The Afghan Ministry of Public Health expresses a commitment to gender equity, but policies on gender are restricted to reproductive health, thus constraining a gender-equity approach as focused on maternal and child health. Our explicit gender analysis not only reveals gender inequities in the Afghan CHW Program and the broader health system, it also uncovers how a highly gendered division of health labour provides some opportunities for women's empowerment that can disrupt patriarchal role constraints and broader gender inequities.

Costs, contracts and the narrative of prosperity: an economic analysis of smallholder tobacco farming livelihoods in Kenya.

BACKGROUND: The tobacco industry has used the alleged negative impacts on economic livelihoods for tobacco farmers as a narrative to oppose tobacco control measures in low/middle-income countries. However, rigorous empirical evidence to support or refute this claim remains scarce. Accordingly, we assess how much money households earn from selling tobacco, and the costs they incur to produce the crop, including labour inputs. We also evaluate farmers' decision to operate under contract directly with tobacco manufacturers and tobacco leaf-buying companies or to operate as independent farmers. METHODS: A stratified random sampling method was used to implement a nationally representative household-level economic survey of 585 farmers across the three main tobacco growing regions in Kenya. The survey was augmented with focus group discussions in all three regions to refine and enrich the context of the findings. RESULTS: Both contract and independent farmers experience small profit margins per acre, with contract farmers operating at a loss. Even when family labour is excluded from the calculation, income levels remain low, particularly considering the typically large households. Generally, tobacco farmers enter into contracts with tobacco companies because they have a 'guaranteed' buyer for their tobacco leaf and receive the necessary agricultural inputs (fertiliser, seeds, herbicides and so on) without paying cash up-front. CONCLUSIONS: Tobacco farming households enter into contract with tobacco companies to realise perceived economic benefits. The narrative that tobacco farming is a lucrative economic undertaking for smallholder farmers, however, is inaccurate in the context of Kenya.

Opening windows and closing gaps: a case analysis of Canada's 2009 tobacco additives ban and its policy lessons.

BACKGROUND: In 2009, Canada adopted legislation (Bill C-32) restricting the sale of flavoured tobacco products, one of the first in the world. This study examines the agenda-setting process leading to the adoption of Bill C-32. METHODS: This research was conducted using a case study design informed by Kingdon's Multiple Streams framework and Heclo's policy learning approach. In-depth interviews were conducted with key informants from government, health-based non-governmental organizations (NGOs), trade associations and the cigar manufacturing sector (n = 11). Public documents produced by media (n = 19), government (n = 11), NGOs (n = 15), as well as technical reports (n = 8) and formal stakeholder submissions (n = 137) were included for analysis. Data were coded with the objective of understanding key events or moments in the lead up to the adoption of Bill C-32 and the actors and arguments in support of and opposition to Bill C-32. RESULTS: The findings point to the importance of a small but active group of NGOs who worked to publicize the issue and eventually take advantage of an open policy window. Our analysis also illustrates that even though consensus was developed about the policy problem and civil society was able to garner political support to address the problem, disagreement and dissent pertaining to the technical dimensions of the policy solution created loopholes for the tobacco industry to exploit. CONCLUSIONS: NGOs remain a critical factor in efforts to strengthen tobacco control policy. These organizations were able to mobilize support for the tobacco flavouring ban adopted at the Federal level in Canada, and although the initial Bill had major limitations to achieving the health objectives, the persistence of these NGOs resulted in amendments to close these loopholes.

Trade challenges at the World Trade Organization to national noncommunicable disease prevention policies: A thematic document analysis of trade and health policy space.

BACKGROUND: It has long been contested that trade rules and agreements are used to dispute regulations aimed at preventing noncommunicable diseases (NCDs). Yet most analyses of trade rules and agreements focus on trade disputes, potentially overlooking how a challenge to a regulation's consistency with trade rules may lead to 'policy or regulatory chill' effects whereby countries delay, alter, or repeal regulations in order to avoid the costs of a dispute. Systematic empirical analysis of this pathway to impact was previously prevented by a dearth of systematically coded data. METHODS AND FINDINGS: Here, we analyse a newly created dataset of trade challenges about food, beverage, and tobacco regulations among 122 World Trade Organization (WTO) members from January 1, 1995 to December 31, 2016. We thematically describe the scope and frequency of trade challenges, analyse economic asymmetries between countries raising and defending them, and summarise 4 cases of their possible influence. Between 1995 and 2016, 93 food, beverage, and tobacco regulations were challenged at the WTO. 'Unnecessary' trade costs were the focus of 16.4% of the challenges. Only one (1.1%) challenge remained unresolved and escalated to a trade dispute. Thirty-nine (41.9%) challenges focussed on labelling regulations, and 18 (19.4%) focussed on quality standards and restrictions on certain products like processed meats and cigarette flavourings. High-income countries raised 77.4% (n = 72) of all challenges raised against low- and lower-middle-income countries. We further identified 4 cases in Indonesia, Chile, Colombia, and Saudi Arabia in which challenges were associated with changes to food and beverage regulations. Data limitations precluded a comprehensive evaluation of policy impact and challenge validity. CONCLUSIONS: Policy makers appear to face significant pressure to design food, beverage, and tobacco regulations that other countries will deem consistent with trade rules. Trade-related influence on public health policy is likely to be understated by analyses limited to formal trade disputes.

How institutional forces, ideas and actors shaped population health planning in Australian regional primary health care organisations.

BACKGROUND: Worldwide, there are competing norms driving health system changes and reorganisation. One such norm is that of health systems' responsibilities for population health as distinct from a focus on clinical services. In this paper we report on a case study of population health planning in Australian primary health care (PHC) organisations (Medicare Locals, 2011-2015). Drawing on institutional theory, we describe how institutional forces, ideas and actors shaped such planning. METHODS: We reviewed the planning documents of the 61 Medicare Locals and rated population health activities in each Medicare Local. We also conducted an online survey and 50 interviews with Medicare Local senior staff, and an interview and focus group with Federal Department of Health staff. RESULTS: Despite policy emphasis on population health, Medicare Locals reported higher levels of effort and capacity in providing clinical services. Health promotion and social determinants of health activities were undertaken on an ad hoc basis. Regulatory conditions imposed by the federal government including funding priorities and time schedules, were the predominant forces constraining population health planning. In some Medicare Locals, this was in conflict with the normative values and what Medicare Locals felt ought to be done. The alignment between the governmental and the cultural-cognitive forces of a narrow biomedical approach privileged clinical practice and ascribed less legitimacy to action on social determinants of health. Our study also shed light on the range of PHC actors and how their agency influenced Medicare Locals' performance in population health. The presence of senior staff or community boards with a strong commitment to population health were important in directing action towards population health and equity. CONCLUSIONS: There are numerous institutional, normative and cultural factors influencing population health planning. The experience of Australian Medicare Locals highlights the difficulties of planning in such a way that the impact of the social determinants on health and health equity are taken into account. The policy environment favours a focus on clinical services to the detriment of health promotion informed by a social determinants focus.

Global tobacco control and economic norms: an analysis of normative commitments in Kenya, Malawi and Zambia.

Tobacco control norms have gained momentum over the past decade. To date 43 of 47 Sub-Saharan African countries are party to the Framework Convention on Tobacco Control (FCTC). The near universal adoption of the FCTC illustrates the increasing strength of these norms, although the level of commitment to implement the provisions varies widely. However, tobacco control is enmeshed in a web of international norms that has bearing on how governments implement and strengthen tobacco control measures. Given that economic arguments in favor of tobacco production remain a prominent barrier to tobacco control efforts, there is a continued need to examine how economic sectors frame and mobilize their policy commitments to tobacco production. This study explores the proposition that divergence of international norms fosters policy divergence within governments. This study was conducted in three African countries: Kenya, Malawi, and Zambia. These countries represent a continuum of tobacco control policy, whereby Kenya is one of the most advanced countries in Africa in this respect, whereas Malawi is one of the few countries that is not a party to the FCTC and has implemented few measures. We conducted 55 key informant interviews (Zambia = 23; Kenya = 17; Malawi = 15). Data analysis involved deductive coding of interview transcripts and notes to identify reference to international norms (i.e. commitments, agreements, institutions), coupled with an inductive analysis that sought to interpret the meaning participants ascribe to these norms. Our analysis suggests that commitments to tobacco control have yet to penetrate non-health sectors, who perceive tobacco control as largely in conflict with international economic norms. The reasons for this perceived conflict seems to include: (1) an entrenched and narrow conceptualization of economic development norms, (2) the power of economic interests to shape policy discourses, and (3) a structural divide between sectors in the form of bureaucratic silos.

The institutional context of tobacco production in Zambia.

BACKGROUND: Tobacco production is said to be an important contributor to Zambia's economy in terms of labour and revenue generation. In light of Zambia's obligations under the WHO Framework Convention of Tobacco Control (FCTC) we examined the institutional actors in Zambia's tobacco sector to better understand their roles and determine the institutional context that supports tobacco production in Zambia. METHODS: Findings from 26 qualitative, semi-structured individual or small-group interviews with key informants from governmental, intergovernmental and non-governmental organisations were analysed, along with data and information from published literature. RESULTS: Although Zambia is obligated under the FCTC to take steps to reduce tobacco production, the country's weak economy and strong tobacco interests make it difficult to achieve this goal. Respondents uniformly acknowledged that growing the country's economy and ensuring employment for its citizens are the government's top priorities. Lacklustre coordination and collaboration between the institutional actors, both within and outside government, contributes to an environment that helps sustain tobacco production in the country. A Tobacco Products Control Bill has been under review for a number of years, but with no supply measures included, and with no indication of when or whether it will be passed. CONCLUSIONS: As with other low-income countries involved in tobacco production, there is inconsistency between Zambia's economic policy to strengthen the country's economy and its FCTC commitment to regulate and control tobacco production. The absence of a whole-of-government approach towards tobacco control has created an institutional context of duelling objectives, with some government ministries working at cross-purposes and tobacco interests left unchecked. With no ultimate coordinating authority, this industry risks being run according to the desire and demands of multinational tobacco companies, with few, if any, checks against them.

TOBACCO, TRADE, AND THE RIGHT TO HEALTH.

This article describes how states which have committed to the right to health in international human rights law are obligated to take measures to respect and fulfill this right for their citizens, including measures to protect against the harm to health caused by tobacco. It also reaffirms the duality of both international trade and investment law, and international human rights law. Yet challenges are faced in controlling tobacco production and sale, despite the WHO Framework Convention on Tobacco Control. Recent cases are reviewed wherein health and economic norms embodied in trade and investment rules have intersected.

Disentangling regional trade agreements, trade flows and tobacco affordability in sub-Saharan Africa.

BACKGROUND: In principle, trade and investment agreements are meant to boost economic growth. However, the removal of trade barriers and the provision of investment incentives to attract foreign direct investments may facilitate increased trade in and/or more efficient production of commodities considered harmful to health such as tobacco. We analyze existing evidence on trade and investment liberalization and its relationship to tobacco trade in Sub-Saharan African countries. METHODS: We compare tobacco trading patterns to foreign direct investments made by tobacco companies. We estimate and compare changes in the Konjunkturforschungsstelle (KOF) Economic Globalization measure, relative price measure and cigarette prices. RESULTS: Preferential regional trade agreements appear to have encouraged the consolidation of cigarette production, which has shaped trading patterns of tobacco leaf. Since 2002, British American Tobacco has invested in tobacco manufacturing facilities in Nigeria, Kenya and South Africa strategically located to serve different regions in Africa. Following this, British America Tobacco closed factories in Ghana, Rwanda, Uganda, Mauritius and Angola. At the same time, Malawi and Tanzania exported a large percentage of tobacco leaf to European countries. After 2010, there was an increase in tobacco exports from Malawi and Zambia to China, which may be a result of preferential trade agreements the EU and China have with these countries. Economic liberalization has been accompanied by greater cigarette affordability for the countries included in our analysis. However, only excise taxes and income have an effect on cigarette prices within the region. CONCLUSIONS: These results suggest that the changing economic structures of international trade and investment are likely heightening the efficiency and effectiveness of the tobacco industry. As tobacco control advocates consider supply-side tobacco control interventions, they must consider carefully the effects of these economic agreements and whether there are ways to mitigate them.