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Ansah EW, Maneen S, Ephraim A, Ocloo JEY, Barnes MN, Botha NN. Politics-evidence conflict in national health policy making in Africa: a scoping review. Health Res Policy Syst 2024; 22:47. [PMID: 38622666 PMCID: PMC11017532 DOI: 10.1186/s12961-024-01129-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 03/05/2024] [Indexed: 04/17/2024] Open
Abstract
BACKGROUND Generally, public health policy-making is hardly a linear process and is characterized by interactions among politicians, institutions, researchers, technocrats and practitioners from diverse fields, as well as brokers, interest groups, financiers and a gamut of other actors. Meanwhile, most public health policies and systems in Africa appear to be built loosely on technical and scientific evidence, but with high political systems and ideologies. While studies on national health policies in Africa are growing, there seems to be inadequate evidence mapping on common themes and concepts across existing literature. PURPOSE The study seeks to explore the extent and type of evidence that exist on the conflict between politics and scientific evidence in the national health policy-making processes in Africa. METHODS A thorough literature search was done in PubMed, Cochrane Library, ScienceDirect, Dimensions, Taylor and Francis, Chicago Journals, Emerald Insight, JSTOR and Google Scholar. In total, 43 peer-reviewed articles were eligible and used for this review. RESULT We found that the conflicts to evidence usage in policy-making include competing interests and lack of commitment; global policy goals, interest/influence, power imbalance and funding, morals; and evidence-based approaches, self-sufficiency, collaboration among actors, policy priorities and existing structures. Barriers to the health policy process include fragmentation among actors, poor advocacy, lack of clarity on the agenda, inadequate evidence, inadequate consultation and corruption. The impact of the politics-evidence conflict includes policy agenda abrogation, suboptimal policy development success and policy implementation inadequacies. CONCLUSIONS We report that political interests in most cases influence policy-makers and other stakeholders to prioritize financial gains over the use of research evidence to policy goals and targets. This situation has the tendency for inadequate health policies with poor implementation gaps. Addressing these issues requires incorporating relevant evidence into health policies, making strong leadership, effective governance and a commitment to public health.
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Affiliation(s)
- Edward W Ansah
- Department of Health, Physical Education and Recreation (HPER), University of Cape Coast, Cape Coast, Ghana
| | - Samuel Maneen
- Department of Health, Physical Education and Recreation (HPER), University of Cape Coast, Cape Coast, Ghana
| | - Anastasia Ephraim
- Department of Health, Physical Education and Recreation (HPER), University of Cape Coast, Cape Coast, Ghana
| | - Janet E Y Ocloo
- Department of Health, Physical Education and Recreation (HPER), University of Cape Coast, Cape Coast, Ghana
| | - Mabel N Barnes
- Department of Health, Physical Education and Recreation (HPER), University of Cape Coast, Cape Coast, Ghana
| | - Nkosi N Botha
- Department of Health, Physical Education and Recreation (HPER), University of Cape Coast, Cape Coast, Ghana.
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Akselrod S, Collins TE, Berlina D, De Pinho Campos K, Fones G, de Sousa Neves D, Bashir F, Allen LN. Multisectoral action to address noncommunicable diseases: lessons from three country case studies. Front Public Health 2024; 12:1303786. [PMID: 38450149 PMCID: PMC10915276 DOI: 10.3389/fpubh.2024.1303786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 01/22/2024] [Indexed: 03/08/2024] Open
Abstract
Introduction Multisectoral action is a central component of the global response to the rising prevalence of non-communicable diseases (NCDs). In this paper we aimed to unpack the definition of multisectoral action and provide an overview of the historical context, challenges, and recommendations alongside three country case studies: salt reduction in the UK, tobacco legislation in Nigeria, and regulation of edible oils in Iran. Methods We used an iterative review process to select three country case studies from a list of 20 potential cases previously identified by WHO. At our third round of review we unanimously agreed to focus on salt reduction in the UK, tobacco regulation in Nigeria, and edible oil regulation in Iran as these represented rich cases on diverse risk factors from three different world regions that we felt offered important lessons. We conducted literature reviews to identify further data for each case study. Results Across the three studies a number of important themes emerged. We found that multisectoral approaches demand the often difficult reconciliation of competing and conflicting values and priorities. Across our three chosen cases, commercial interests and free trade agreements were the most common obstacles to successful multisectoral strategies. We found that early consultative stakeholder engagement and strong political and bureaucratic leadership were necessary for success. Discussion The complex multi-rooted nature of NCDs requires a multisectoral approach, but the inevitable conflicts that this entails requires careful navigation.
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Affiliation(s)
| | | | | | | | - Guy Fones
- World Health Organization, Geneva, Switzerland
| | | | | | - Luke N. Allen
- Healthier Systems Ltd., Streatley, United Kingdom
- London School of Hygiene and Tropical Medicine, University of London, London, United Kingdom
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Gangopadhyay A. Ultraprocessed Foods and Cancer in Low-Middle-Income Countries. Nutr Cancer 2023; 75:1863-1873. [PMID: 37873656 DOI: 10.1080/01635581.2023.2272814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 10/13/2023] [Indexed: 10/25/2023]
Abstract
Low middle income countries (LMICs) are the predominant contributors to global cancer-related mortality and are projected to bear the greater share of the global cancer burden in the next few decades. Among other factors, lifestyle changes have been linked to the rising incidence of cancer in these countries. As one of the keys to a healthy lifestyle, a balanced diet plays a major role in the preservation of health. Globalization and rapid urbanization have prompted a paradigm shift in various aspects of daily life in LMICs; the influence on dietary choices has been particularly noticeable. Studies show a concerning rise in the sale and consumption of ultraprocessed foods in these countries. In addition to hyperpalatability, this trend has been attributed to various other factors including convenience, availability, economic considerations, and marketing strategies. Although several studies from LMICs recognize and recommend the need for effective public health measures to reduce the consumption of these foods, findings from certain studies suggest that established public health strategies occasionally fail in the real-world scenario. Barriers to effective policymaking also contribute to the prevailing dietary trends. This review of studies from the LMIC setting demonstrates the current problem, limitations of established public health measures, and the complexities associated with effective policymaking. In view of the threat posed to cancer risk, there is an urgent need to curb the consumption of ultraprocessed foods in LMICs. National policymakers therefore need to circumnavigate the challenges effectively to ensure timely achievement of the United Nations sustainable development goals.
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Alvarado M, Adams J, Penney T, Murphy MM, Abdool Karim S, Egan N, Rogers NT, Carters-White L, White M. A systematic scoping review evaluating sugar-sweetened beverage taxation from a systems perspective. NATURE FOOD 2023; 4:986-995. [PMID: 37857862 PMCID: PMC10661741 DOI: 10.1038/s43016-023-00856-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 09/08/2023] [Indexed: 10/21/2023]
Abstract
Systems thinking can reveal surprising, counterintuitive or unintended reactions to population health interventions (PHIs), yet this lens has rarely been applied to sugar-sweetened beverage (SSB) taxation. Using a systematic scoping review approach, we identified 329 papers concerning SSB taxation, of which 45 considered influences and impacts of SSB taxation jointly, involving methodological approaches that may prove promising for operationalizing a systems informed approach to PHI evaluation. Influences and impacts concerning SSB taxation may be cyclically linked, and studies that consider both enable us to identify implications beyond a predicted linear effect. Only three studies explicitly used systems thinking informed methods. Finally, we developed an illustrative, feedback-oriented conceptual framework, emphasizing the processes that could result in an SSB tax being increased, maintained, eroded or repealed over time. Such a framework could be used to synthesize evidence from non-systems informed evaluations, leading to novel research questions and further policy development.
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Affiliation(s)
- Miriam Alvarado
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Institute of Metabolic Science, Cambridge Biomedical Campus, Cambridge, UK.
| | - Jean Adams
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Institute of Metabolic Science, Cambridge Biomedical Campus, Cambridge, UK
| | - Tarra Penney
- Global Food System and Policy Research, School of Global Health, Faculty of Health, York University, Toronto, Ontario, Canada
| | - Madhuvanti M Murphy
- George Alleyne Chronic Disease Research Centre, Caribbean Institute for Health Research, The University of the West Indies, Bridgetown, Barbados
| | | | - Nat Egan
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Institute of Metabolic Science, Cambridge Biomedical Campus, Cambridge, UK
| | - Nina Trivedy Rogers
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Institute of Metabolic Science, Cambridge Biomedical Campus, Cambridge, UK
| | - Lauren Carters-White
- SPECTRUM Consortium, Usher Institute of Population Health Sciences and Informatics, Old Medical School, University of Edinburgh, Edinburgh, UK
| | - Martin White
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Institute of Metabolic Science, Cambridge Biomedical Campus, Cambridge, UK
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Singh A, Smith K, Hellowell M, Logo DD, Marten R, Suu K, Owusu-Dabo E. An exploration of stakeholder views and perceptions on taxing tobacco, alcohol and sugar-sweetened beverages in Ghana. BMJ Glob Health 2023; 8:e012054. [PMID: 37257939 PMCID: PMC10255295 DOI: 10.1136/bmjgh-2023-012054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 05/14/2023] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND Non-communicable diseases (NCDs) account for nearly 43% of Ghana's all-cause mortality. Unhealthy commodities (such as alcohol, sugar and tobacco) are an important factor in the growing NCD burden in the region of sub-Saharan Africa (SSA). Despite health taxes on tobacco, alcohol and sugar-sweetened beverages (SSBs) gaining renewed attention, adoption and implementation in SSA remain limited. This study aims to unpack the contextual politics and to examine current perceptions of opportunities and barriers for health taxes in Ghana. METHODS Semistructured qualitative interviews (n=19) conducted with purposively sampled stakeholders representing four sectors: government, civil society, media and international organisations, and two group interviews with nine industry stakeholders, informed by a review of relevant literature and policy/advocacy documents. RESULTS Stakeholders had a general belief that such taxes are primarily useful for revenue generation (for health spending) rather than for reducing consumption and improving health. There do appear to be opportunities for health taxes with stakeholders broadly supportive of taxing SSBs. This support could be strengthened via 'health' framing of any new tax proposals, the generation of Ghana-specific evidence about the potential impacts of such taxes and greater public awareness. Industry actors and some government representatives opposed health taxes, citing concerns about the potential to increase illicit trade and economic harm. Some stakeholders also believed that links between politicians and affected industries represent an important barrier. CONCLUSION These findings identify opportunities to introduce health taxes but also underline the potential resistance from affected industry stakeholders. Nevertheless, a strategic approach that focuses on achieving policy coherence (between central government, health and economic ministries), combined with efforts to strengthen stakeholder and public support, may weaken the lobbying position of industry. Such efforts could be supported by research to help demonstrate the value of different designs of health taxes for achieving Ghana's health goals and to better understand industry-political links.
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Affiliation(s)
- Arti Singh
- School of Public Health, KNUST, Kumasi, Ghana
| | - Katherine Smith
- School of Social Work and Social Policy, University of Strathclyde, Glasgow, UK
| | - Mark Hellowell
- School of Social and Political Science, University of Edinburgh, Edinburgh, UK
| | | | - Robert Marten
- WHO Alliance for Health Policy and Systems Research, Geneva, Switzerland
| | - Kaung Suu
- Alliance For Health Policy and System Research, Geneva, Switzerland
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Thow AM, Erzse A, Asiki G, Ruhara CM, Ahaibwe G, Ngoma T, Amukugo HJ, Wanjohi MN, Mukanu MM, Gaogane L, Abdool Karim S, Hofman K. Study design: policy landscape analysis for sugar-sweetened beverage taxation in seven sub-Saharan African countries. Glob Health Action 2021; 14:1856469. [PMID: 33475471 PMCID: PMC7833028 DOI: 10.1080/16549716.2020.1856469] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
This paper reports on the design of a study to examine the policy landscape relevant to sugar-sweetened beverage taxation in seven sub-Saharan African countries. The study responds to the need for strong policy to address the rising burden of non-communicable diseases in the region. Sugar-sweetened beverage taxation has been widely recommended as a key component of a comprehensive policy approach to NCD prevention. However, it has proved a contentious policy intervention, with industry strongly opposing the introduction of such taxes. The aim was to identify opportunities to strengthen sugar-sweetened beverage taxation-related policy for the prevention of nutrition-related NCDs in a subset of Eastern and Southern African countries: Kenya, Tanzania, Botswana, Rwanda, Namibia, Zambia, Uganda. The study was conducted as a collaboration by researchers from nine institutions; including the seven study countries, South Africa, and Australia. The research protocol was collaboratively developed, drawing on theories of the policy process to examine the existing availability of evidence, policy context, and stakeholder interests and influence. This paper describes the development of a method for a policy landscape analysis to strengthen policies relevant to NCD prevention, and specifically sugar-sweetened beverage taxation. This takes the form of a prospective policy analysis, based on systematic documentary analysis supplemented by consultations with policy actors, that is feasible in low-resource settings. Data were collected from policy documents, government and industry reports, survey documentation, webpages, and academic literature. Consultations were conducted to verify the completeness of the policy-relevant data collection. We analysed the frames and beliefs regarding the policy ‘problems’, the existing policy context and understandings of sugar-sweetened beverage taxation as a potential policy intervention, and the political context across relevant sectors, including industry interests and influence in the policy process. This study design will provide insights to inform public health action to support sugar-sweetened beverage taxation in the region.
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Affiliation(s)
- Anne-Marie Thow
- Menzies Centre for Health Policy, School of Public Health, The University of Sydney , Sydney, Australia
| | - Agnes Erzse
- SAMRC Centre for Health Economics and Decision Science - Priority Cost Effective Lessons for Systems Strengthening (PRICELESS SA), University of the Witwatersrand, School of Public Health , Johannesburg, South Africa
| | - Gershim Asiki
- School of Economics, University of Rwanda , Butare, Rwanda
| | | | - Gemma Ahaibwe
- Economic Policy Research Centre (EPRC), Makerere University , Kampala, Uganda
| | - Twalib Ngoma
- Oncology Department, Muhimbili University of Health and Allied Sciences , Dar Es Salaam, Tanzania
| | - Hans Justus Amukugo
- Community Health Department, School of Nursing, Faculty of Health Sciences, University of Namibia , Windhoek, Namibia
| | - Milka N Wanjohi
- Health and Systems for Health Unit, African Population and Health Research Center , Nairobi, Kenya
| | - Mulenga M Mukanu
- Health Policy and Management Unit, University of Zambia School of Public Health , Lusaka, Zambia
| | - Lebogang Gaogane
- Department of Health Promotion & Education, Boitekanelo College , Gaborone, Botswana
| | - Safura Abdool Karim
- SAMRC Centre for Health Economics and Decision Science - Priority Cost Effective Lessons for Systems Strengthening (PRICELESS SA), University of the Witwatersrand, School of Public Health , Johannesburg, South Africa
| | - Karen Hofman
- SAMRC Centre for Health Economics and Decision Science - Priority Cost Effective Lessons for Systems Strengthening (PRICELESS SA), University of the Witwatersrand, School of Public Health , Johannesburg, South Africa
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Ndlovu N, Swinburn B. Readiness for sugar sweetened beverage taxation in sub-Saharan Africa. Glob Health Action 2021; 14:1917801. [PMID: 33877015 PMCID: PMC8079043 DOI: 10.1080/16549716.2021.1917801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Affiliation(s)
- Ntombizodwa Ndlovu
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Boyd Swinburn
- School of Population Health, University of Auckland, Auckland, New Zealand
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Thow AM, Abdool Karim S, Mukanu MM, Ahaibwe G, Wanjohi M, Gaogane L, Amukugo HJ, Ruhara CM, Ngoma T, Asiki G, Erzse A, Hofman K. The political economy of sugar-sweetened beverage taxation: an analysis from seven countries in sub-Saharan Africa. Glob Health Action 2021; 14:1909267. [PMID: 33877032 PMCID: PMC8078959 DOI: 10.1080/16549716.2021.1909267] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background: Non-communicable diseases are on the rise across sub-Saharan Africa. The region has become a targeted growth market for sugar-sweetened beverages, which are associated with weight gain, cardiovascular diseases and diabetes.Objective: To identify politico-economic factors relevant to nutrition-related fiscal policies, and to draw lessons regarding strategies to strengthen sugar-sweetened beverages taxation in the region and globally.Methods: We collected documentary data on policy content, stakeholders and corporate political activity from seven countries in east and southern Africa augmented by qualitative interviews in Botswana, Namibia, Kenya and Zambia, and stakeholder consultations in Rwanda, Tanzania and Uganda. Data were analysed using a political economy framework, focusing on ideas, institutions, interests and power, and a 'bricolage' approach was employed to identify strategies for future action.Results: Non-communicable diseases were recognised as a priority in all countries. Kenya, Zambia, Rwanda, Tanzania and Uganda had taxes on non-alcoholic beverages, which varied in rate and tax base, but appeared to be motivated by revenue rather than health concerns. Botswana and Namibia indicated intention to adopt sugar-sweetened beverage taxes. Health-oriented sugar-sweetened beverage taxation faced challenges from entrenched economic policy paradigms for industry-led economic growth and was actively opposed by sugar-sweetened beverage-related industries. Strategies identified to support stronger sugar-sweetened beverage taxation included shifting the economic discourse to strengthen health considerations, developing positive public opinion, forging links with the agriculture sector for shared benefit, and leadership by a central government agency.Conclusions: There are opportunities for more strategic public health engagement with the economic sector to foster strong nutrition-related fiscal policy for non-communicable disease prevention in the region.
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Affiliation(s)
- Anne Marie Thow
- Menzies Centre for Health Policy, School of Public Health, Charles Perkins Centre, The University of Sydney, Sydney, Australia
| | - Safura Abdool Karim
- SAMRC/Centre for Health Economics and Decision Science - Priority Cost Effective Lessons for Systems Strengthening (PRICELESS SA), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Mulenga M Mukanu
- Health Policy and Management Unit, University of Zambia School of Public Health, Lusaka, Zambia
| | - Gemma Ahaibwe
- Economic Policy Research Centre (EPRC), Makerere University, Kampala, Uganda
| | | | - Lebogang Gaogane
- Department of Health Promotion & Education, Boitekanelo College, Gaborone, Botswana
| | - Hans Justus Amukugo
- Community Health Department, School of Nursing, Faculty of Health Sciences, University of Namibia, Windhoek, Namibia
| | | | - Twalib Ngoma
- Economic Social Research Foundation (ESFR), Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - Agnes Erzse
- SAMRC/Centre for Health Economics and Decision Science - Priority Cost Effective Lessons for Systems Strengthening (PRICELESS SA), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Karen Hofman
- SAMRC/Centre for Health Economics and Decision Science - Priority Cost Effective Lessons for Systems Strengthening (PRICELESS SA), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
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