Analysing coordination and coherence in non-communicable disease policies: governance challenges in tobacco control and nutrition in South East Asia
Creators: name: John, Shoba
Publisher: name: The University of Edinburgh
Year: 2023
Subjects: policy coherence
policy coordination
Noncommunicable disease governance
health governance
global governance models
multisectoralism
multistakeholderism
partnerships

description: BACKGROUND: Alongside longstanding hurdles to promoting whole of government approaches to health policy, the commitment to ensuring policy coherence has emerged as one of the defining challenges of the UN Sustainable Development Goals. Coordination and coherence barriers are often experienced as particularly acute in the context of non-communicable diseases (NCDs), given both divergent approaches to regulation across NCD policy spheres and scope for tensions between health goals and key economic interests. This thesis seeks to address the dearth of substantive research examining such challenges across NCD risk factors and levels of governance. Barriers and facilitators for coordination and coherence in health governance are examined via case studies of the Conference of Parties (COP) of the Framework Convention on Tobacco Control (FCTC), focused on the World Health Organization South East Asia region (WHO SEARO), and of the Scaling Up Nutrition (SUN) initiative in Bangladesh. METHODS: Qualitative research involving two multi-level case studies — focusing on tobacco and nutrition governance respectively — was conducted in the context of WHO SEARO. Data collection involved semi-structured interviews — 22 in the tobacco case study and 26 for nutrition — of representatives from governmental, intergovernmental and non-governmental agencies, academia and private sector affiliates. Interview data were thematically analysed using an interpretative approach that involved interpreting policymaking as a social construct. Analysis of interview data was complemented by documentary review. RESULTS: In the tobacco case study, which focused on an initiative to enhance transparency of COP delegations, interview findings suggested that SEARO countries sought to use the COP as a platform to promote vertical coherence across national and international levels. However, identified barriers to developing coherence included weak health leadership, lack of financial resources and poor communication on FCTC commitments that impeded in-country coordination and participation in COPs. Tensions between diverse sectoral goals raised challenges for policy making, defining national priorities, and for advancing regional coordination. The competing priority norms of low-and middle-income countries and high-income ones pitting public health safeguards against public accountability measures also obstructed COP-wide coordination. Some SEARO countries reported overcoming these hurdles by prioritising tobacco control and building safeguards against tobacco industry interference in national policy making alongside active health sector leadership, engagement of non-health sectors and setting up coordination systems for COP preparations. Networks of countries at regional and COP levels were seen to consolidate and facilitate development of a COP decision to enhance transparency of their delegations. The nutrition case study explored mechanisms and programmes of the SUN initiative in Bangladesh that bring together government agencies, civil society, academia and the private sector to develop a multisectoral and multistakeholder approach to nutrition policies. SUN’s advocacy was reported to have increased awareness, stimulated nutrition-sensitive initiatives, raised the need for funding and promoted nutrition in the national development agenda. The nutrition response in Bangladesh, however, was considered to be fragmented as exemplified in the case of food fortification initiatives, and strained with regard to the country’s response to a growing obesity burden on NCD prevention. Tensions in reconciling health and economic goals were seen as inhibiting the development of coherent nutrition policy. In this context, the analysis highlighted the significance of polarisation regarding SUN’s promotion of multistakeholderism. While its multistakeholder platform was widely perceived to facilitate coordination and resource mobilisation, some interviewees expressed apprehension about SUN influencing national nutrition and advancing the interests of donors and businesses. The involvement of food companies was similarly contested, with international partners with business links promoting industry engagement, and public officials and civil society from Bangladesh concerned about perceived conflicts of interest. Overall, interviewees considered SUN’s conflict of interest mechanisms inadequate to deal with the country’s vulnerabilities. CONCLUSION: Findings illustrate how efforts to promote policy coordination and coherence compare and contrast in two key global health governance platforms relevant to NCD prevention: the FCTC and SUN partnership. There are implications for coordination in terms of conflicts between sectoral goals, resource constraints, information gaps, tensions among stakeholders and commercial sector involvement for collaborative actions at regional and international levels. Findings also highlights the role of international norms and platforms in facilitating vertical coherence in global health governance. Coordination and coherence in health governance in low- and middle-income countries could be supported through enhanced resource allocation, improved sharing of information, frameworks to effectively address conflicts of interest and mechanisms for civil society contributions.