A sweet deal for domestic industry: the political economy and framing of Vanuatu's sugar-sweetened beverage tax.

INTRODUCTION: The Government of Vanuatu introduced an excise tax on sugar-sweetened beverages (SSBs) in 2015. While lauded for its alignment with the WHO's Best Buys recommendations for addressing non-communicable diseases (NCDs), little is known about the tax's adoption process or whose interests it serves. METHODS: Using case study methodology, this study examined how and why Vanuatu's SSB tax was introduced. Policy documents, key informant interviews (n=33) and direct observations were analysed using theories of policy analysis, power analysis and postcolonial theory to map the policy's adoption, surrounding political economy and the ideas, interests and institutions that shaped the tax and its framing. RESULTS: The SSB tax emerged during a politically and economically unstable time in Vanuatu's history. The tax's links to the national health agenda were tenuous despite its ostensible framing as a way to combat NCDs. Rather, the tax was designed to respond to tightening economic and trade conditions. Spearheaded by several finance-focused bureaucrats, and with limited input from health personnel, the tax targeted less frequently consumed carbonated SSBs (which are mostly imported) without any revenue reinvestments into health. Driven by the desire to generate much-needed government revenue and instal domestic protections via selective implementation and carve-outs for local producers, the Vanuatu SSB tax did meet national objectives, just not the dual health and economic 'win-win' projected by the NCD Best Buys. CONCLUSION: Vanuatu's SSB tax adoption process reveals the limitations of decontextualised policy recommendations, such as the NCD Best Buys, whose framing may be overcome by local political realities. This research highlights the need for further political economy considerations in global health recommendations, since contextual forces and power dynamics are key to shaping both how and why policies are enacted and also whose interest they serve.

Research protocol for impact assessment of a project to scale up food policies in the Pacific.

BACKGROUND: One of the challenges for countries implementing food policy measures has been the difficulty in demonstrating impact and retaining stakeholder support. Consequently, research funded to help countries overcome these challenges should assess impact and translation into practice, particularly in low-resource settings. However, there are still few attempts to prospectively, and comprehensively, assess research impact. This protocol describes a study co-created with project implementers, collaborative investigators and key stakeholders to optimize and monitor the impact of a research project on scaling up food policies in Fiji. METHODS: To develop this protocol, our team of researchers prospectively applied the Framework to Assess the Impact from Translational health research (FAIT). Activities included (i) developing a logic model to map the pathway to impact and establish domains of benefit; (ii) identifying process and impact indicators for each of these domains; (iii) identifying relevant data for impact indicators and a cost-consequence analysis; and (iv) establishing a process for collecting quantitative and qualitative data to measure progress. Impact assessment data will be collected between September 2022 and December 2024, through reports, routine monitoring activities, group discussions and semi-structured interviews with key implementers and stakeholders. The prospective application of the protocol, and interim and final research impact assessments of each project stream and the project as a whole, will optimize and enable robust measurement of research impact. DISCUSSION: By applying this protocol, we aim to increase understanding of pathways to impact and processes that need to be put in place to achieve this. This impact evaluation will inform future projects with a similar scope and will identify transferable and/or translatable lessons for other Pacific Island states and low- and middle-income countries.

Incorporating a gender lens into nutrition and health-related policies in Fiji: analysis of policies and stakeholder perspectives.

BACKGROUND: Gender equality, zero hunger and healthy lives and well-being for all, are three of the Sustainable Development Goals (SDGs) that underpin Fiji's National Development Plan. Work towards each of these goals contributes to the reduction of non-communicable diseases (NCDs). There are gender differences in NCD burden in Fiji. It is, however, unclear whether a gender lens could be more effectively included in nutrition and health-related policies. METHODS: This study consisted of three components: (i) a policy content analysis of gender inclusion in nutrition and health-related policies (n = 11); (ii) policy analysis using the WHO Gender Analysis tool to identify opportunities for strengthening future policy; and (iii) informant interviews (n = 18), to understand perceptions of the prospects for gender considerations in future policies. RESULTS: Gender equality was a goal in seven policies (64%); however, most focused on women of reproductive age. One of the policies was ranked as gender responsive. Main themes from key informant interviews were: 1) a needs-based approach for the focus on specific population groups in policies; 2) gender-related roles and responsibilities around nutrition and health; 3) what is considered "equitable" when it comes to gender, nutrition, and health; 4) current considerations of gender in policies and ideas for further gender inclusion; and 5) barriers and enablers to the inclusion of gender considerations in policies. Informants acknowledged gender differences in the burden of nutrition-related NCDs, yet most did not identify a need for stronger inclusion of gender considerations within policies. CONCLUSIONS: There is considerable scope for greater inclusion of gender in nutrition and health-related policies in Fiji. This could be done by: 1) framing gender considerations in ways that are actionable and inclusive of a range of gender identities; 2) undertaking advocacy through actor networks to highlight the need for gender-responsive nutrition and health-related policies for key stakeholder groups; 3) ensuring that data collected to monitor policy implementation is disaggregated by sex and genders; and 4) promoting equitable participation in nutrition related issues in communities and governance processes. Action on these four areas are likely critical enablers to more gender equitable NCD reduction in Fiji.

Assessing the progress on the implementation of policy and legislation actions to address the Non-Communicable Diseases crisis in the Pacific.

AIM: To assess the progress on the implementation of Non-Communicable Diseases (NCD) related policies and legislations in the Pacific Island Countries and Territories (PICTs). MATERIALS AND METHODS: The Pacific Monitoring Alliance for NCD Action (MANA) Dashboard was used to assess the progress on the implementation. The MANA Dashboard includes 31 indicators across four different domains such as leadership and governance; preventative policies and legislations; health system response programs; and monitoring This progress assessment was conducted between 2019 and 2020 for all 21 PICTs. The data were analyzed and compared with the baseline status (2018) report and presented across four different domains of the MANA dashboard. RESULTS: This progress assessment found that PICTs overall have made advancements in a number of areas, particularly the establishment of a national multi-sectoral NCD taskforce; implementation of referenced approaches to restrict trans-fat in the food supply in national documents; and fiscal measures to affect access and availability to less healthy foods and drinks. However, the strengths of actions varied across PICTs, and most are categorised as low strengths. Measures which had the most limited progress in implementation include policy and legislation that restrict alcohol advertising; tobacco industry interference; marketing of foods and non-alcoholic beverages to children; and marketing for breast milk substitutes. CONCLUSIONS: This progress assessment further highlights that while PICTs continue to make progress, NCD policy and legislation gaps still exist, both in terms of weaknesses of existing measures and areas that have had little attention to-date. These require urgent actions to scale up NCD related policies and legislation at regional and national level.

Strengthening Sugar-Sweetened Beverage Taxation for Non-Communicable Disease Prevention: A Comparative Political Economy Analysis Case Study of Fiji and Tonga.

Diet-related fiscal policy is an effective NCD prevention strategy. However, current sugar-sweetened beverage (SSB) taxes in Fiji and Tonga have not had the desired effect; SSB consumption in Fiji, for example, contributes to mortality more than double the global rates and is highest in the WHO Western Pacific Region. We therefore aimed to better understand the perceived underlying political economy drivers that have and continue to affect change in each country. Our study design utilised a comparative case study that triangulated documentary policy and stakeholder analysis with semi-structured stakeholder interviews in both countries and an in-depth corporate political activity analysis in Fiji. We drew on theoretical frameworks relevant to political economy to collect and analyse policy and stakeholder data, and utilised established corporate political activity frameworks to analyse industry activity. Common findings to both Fiji and Tonga suggested that the SSB tax impact could be increased through multisectoral engagement, embracing a whole-of-society approach, strengthened institutional structures and leveraging off competing priorities across sectors towards more common goals. These findings provide opportunities and lessons for Fiji and Tonga as well as other similar settings seeking to strengthen or upscale the impact of diet-related fiscal policy.

Scaling-up food policies in the Pacific Islands: protocol for policy engagement and mixed methods evaluation of intervention implementation.

BACKGROUND: There is a crisis of non-communicable diseases (NCDs) in the Pacific Islands, and poor diets are a major contributor. The COVID-19 pandemic and resulting economic crisis will likely further exacerbate the burden on food systems. Pacific Island leaders have adopted a range of food policies and regulations to improve diets. This includes taxes and regulations on compositional standards for salt and sugar in foods or school food policies. Despite increasing evidence for the effectiveness of such policies globally, there is a lack of local context-specific evidence about how to implement them effectively in the Pacific. METHODS: Our 5-year collaborative project will test the feasibility and effectiveness of policy interventions to reduce salt and sugar consumption in Fiji and Samoa, and examine factors that support sustained implementation. We will engage government agencies and civil society in Fiji and Samoa, to support the design, implementation and monitoring of evidence-informed interventions. Specific objectives are to: (1) conduct policy landscape analysis to understand potential opportunities and challenges to strengthen policies for prevention of diet-related NCDs in Fiji and Samoa; (2) conduct repeat cross sectional surveys to measure dietary intake, food sources and diet-related biomarkers; (3) use Systems Thinking in Community Knowledge Exchange (STICKE) to strengthen implementation of policies to reduce salt and sugar consumption; (4) evaluate the impact, process and cost effectiveness of implementing these policies. Quantitative and qualitative data on outcomes and process will be analysed to assess impact and support scale-up of future interventions. DISCUSSION: The project will provide new evidence to support policy making, as well as developing a low-cost, high-tech, sustainable, scalable system for monitoring food consumption, the food supply and health-related outcomes.

Barriers and facilitators to the introduction of import duties designed to prevent noncommunicable disease in Tonga: a case study.

BACKGROUND: In Tonga, import duties were lowered on tinned fish and seafood in 2013 and raised on soft drinks, dripping and other animal fats. Additional import duties were applied to soft drinks and dripping and other fats in 2016 and duties were also applied to high fat meats, mutton flaps and turkey tails. The objective of this study was to describe barriers to and facilitators of these import duties from a policy-maker perspective. METHODS: A case study was conducted to analyse implementation of policies originally modelled by the Pacific Obesity Prevention in Communities project to reduce mortality in the Kingdom of Tonga. Policymakers (n = 15) from the Ministries of Revenue, Health, Finance and Labour and Commerce involved in the development and implementation of Tonga's food-related policies participated in key-informant interviews. RESULTS: The main facilitator of import duties were strong leadership and management, cross-sector collaboration, awareness raising and advocacy, nature of the policy, and the effective use of data to model policy impacts and inform the general public. The absence of clear lines of responsibility and a decline in collaboration over time were identified as barriers to implementation of the import duties. CONCLUSION: In a small Island state implementing import duties to prevent non-communicable disease can be straight forward providing policymakers and the community have a shared understanding of the health and economic costs of NCDs.

The political economy of restricting marketing to address the double burden of malnutrition: two case studies from Fiji.

OBJECTIVE: To draw lessons from Fiji regarding the challenges and opportunities for policy initiatives to restrict (i) food marketing to children and (ii) marketing of breast milk substitutes, to inform policy for the double burden of malnutrition. DESIGN: Qualitative political economy analysis of two policy case studies. SETTING: Fiji. PARTICIPANTS: Eleven key informants from relevant sectors, representing public health, economic and consumer interests. RESULTS: This study used two policy initiatives as case studies to examine factors influencing decision-making: Marketing Controls (Foods for Infants and Young Children) Regulations 2010, amended in 2016 to remove guidelines and restrictions on marketing in the form of labelling, and the draft Advertising and Promotion of Unhealthy Foods and Non-Alcoholic Beverages to Children Regulation developed in 2014 but awaiting review by the Solicitor General's Office. Factors identified included: a policy paradigm in which regulation of business activity contradicts economic policy goals; limited perception by key policy actors of links between nutrition and marketing of breast milk substitutes, foods and beverages; and a power imbalance between industry and public health stakeholders in policymaking. Regulation of marketing for health purposes sits within the health sector's interest but not its legislative remit, while within the economic sector's remit but not interest. Opportunities to strengthen restrictions on marketing to improve nutrition and health include reframing the policy issue, strategic advocacy and community engagement. CONCLUSIONS: Restricting marketing should be recognised by public health actors as a public health and an industry policy issue, to support strategic engagement with economic policy actors.

Childhood Obesity in the Pacific: Challenges and Opportunities.

PURPOSE OF REVIEW: Childhood obesity is increasing substantially in many Pacific island countries and poses an urgent and serious challenge. The Sustainable Development Goals set by the United Nations and the NCD Roadmap created at the request of the Pacific Finance and Economic Ministers identify prevention and control of noncommunicable diseases as core priorities. Among the various risk factors responsible for the development of noncommunicable diseases (NCDs), overweight and obesity are particularly of concern with the potential to negate many of the health benefits that have contributed to increased life expectancy. With the increase in childhood obesity across the region, it has become apparent that surveillance data remains a challenge; however, it is essential to inform the development of effective policies and strategies to tackle the challenge of childhood obesity in the Pacific region. RECENT FINDINGS: The paper highlights the paucity of childhood obesity surveillance data available in the Pacific region and how the absence of a standardised tool to collect this data makes it difficult to do comparative analysis between countries. Drawing on a global protocol and identifying the gaps that currently exist in the region, the paper aims to highlight opportunities via which childhood obesity surveillance data can be improved to monitor better childhood obesity across the Pacific region.

Fruit and vegetable import duty reduction in Fiji to prevent obesity and non-communicable diseases: a case study.

OBJECTIVE: To describe the development of Fiji's fruit and vegetable fiscal policies between 2010 and 2014 and explore the impact they have had on import volumes. DESIGN: Qualitative case study and in-depth analysis of policy process. Policy impact was assessed using publicly available import volume data and prices of food products. SETTING: Fiji. PARTICIPANTS: Senior government policy makers, non-communicable disease officers from the Ministry of Health and Medical Services (MoHMS) and supermarket managers. RESULTS: In 2011, the Fijian Government introduced an import excise of 10 % on vegetables and reduced the import fiscal duty on fruit that was also grown in Fiji by 10 %. The import tax on vegetables was removed in 2012 in response to a MoHMS request. Policy makers from several sectors supported the MoHMS request, recognized their leadership and acknowledged the importance of collaboration in achieving the removal of the excise. Tariff reductions appear to have contributed to increases in the volume of vegetables (varieties not grown in Fiji) and fruit (varieties grown in Fiji) imported, but it is not clear if this increased population consumption. CONCLUSIONS: Reductions in import duties appear to have contributed to increases in volumes of vegetables and fruit imported into Fiji. This case study has demonstrated that governments can use fiscal policy to meet the needs of a range of sectors including health, agriculture and tourism.

The development and implementation of a new import duty on palm oil to reduce non-communicable disease in Fiji.

BACKGROUND: Non communicable diseases (NCD) place a significant health burden on Pacific Island countries including Fiji. Policy interventions to curb NCDs have been implemented in Fiji including a 32% increase in the import duty on palm oil. This study aims to analyse the development and implementation of the increase in palm oil import duty in Fiji. Also, to document the policy process, identify barriers and facilitators during implementation and to examine the impact of the new import duty on import volumes. METHODS: Data were collected through key informant interviews with private stakeholders, government officials and supermarket managers. Transcripts were analysed thematically. Import volumes were analysed for the 2010-2015 period. RESULTS: Facilitators of policy development and implementation included stakeholder awareness of the health implications of palm oil, preparation of a comprehensive policy briefing paper, and inter-sectoral support and leadership. This decrease in the availability of palm oil was encouraging however, it may have been counteracted to some extent by industry relabelling the product as vegetable oil. CONCLUSIONS: Barriers to policy changes need to be anticipated during the policy development process. Whilst the decline in imports probably reduced population consumption, further research is needed to determine if this translated to a population wide reduction in saturated fat.

Participants' perceptions of a knowledge-brokering strategy to facilitate evidence-informed policy-making in Fiji.

BACKGROUND: Evidence-informed policy-making (EIPM) is optimal when evidence-producers (researchers) and policy developers work collaboratively to ensure the production and use of the best available evidence. This paper examined participants' perceptions of knowledge-brokering strategies used in the TROPIC (Translational Research in Obesity Prevention in Communities) project to facilitate the use of obesity-related evidence in policy development in Fiji. METHOD: Knowledge-brokers delivered a 12-18 month programme comprising workshops targeting EIPM skills and practical support for developing evidence-informed policy briefs to reduce obesity. The programme was tailored to each of the six participating organizations. Knowledge-brokering strategies included negotiating topics that were aligned to the goals of individual organizations, monitoring and evaluating time-management skills, accommodating other organizational and individual priorities, delivering practical sessions on use of appropriate research tools and supporting individual writing of policy briefs. Two qualitative methods were used to examine individuals' perceptions of skills obtained, opportunities afforded by the TROPIC project, facilitators and inhibiters to planned policy brief development and suggestions for improved programme delivery. Forty-nine participants completed an electronic word table and then participated in a semi-structured interview. An independent interviewer conducted structured interviews with a high-ranking officer in each organization to examine their perceptions of TROPIC engagement strategies. Data were analyzed descriptively and thematically, with the first author and another experienced qualitative researcher analyzing data sets separately, and then combining analyses. RESULTS: Many participants believed that they had increased their skills in acquiring, assessing, adapting and applying evidence, writing policy briefs and presenting evidence-based arguments to higher levels. Many participants preferred one-to-one meetings to group activities to ensure early resolution of developing issues and to refine policy briefs. Perceived barriers to EIPM were lack of knowledge about data sources, inadequate time to develop evidence-informed briefs, and insufficient resources for accessing and managing evidence. CONCLUSION: An innovative knowledge-brokering approach utilizing skill development and mentorship facilitated individual EIPM skills and policy brief development. The TROPIC model could stimulate evidence-based policy action relating to obesity prevention and other policy areas in other Pacific countries and elsewhere.