Implementing effective salt reduction programs and policies in low- and middle-income countries: learning from retrospective policy analysis in Argentina, Mongolia, South Africa and Vietnam

Abstract

Objective: To understand factors influencing implementation of salt reduction interventions in low- and middle-income countries (LMICs). Design: Retrospective policy analysis based on desk reviews of existing reports and semi-structured stakeholder interviews in four countries, using Walt and Gilson’s ‘Health Policy Triangle’ to assess the role of context, content, process and actors on implementation of salt policy. Setting: Argentina, Mongolia, South Africa and Vietnam Results: Global targets and regional consultations were viewed as important drivers of salt reduction interventions in Mongolia and Vietnam in contrast to local research and advocacy, and support from international experts, in Argentina and South Africa. All countries had population-level targets and written strategies with multiple interventions to reduce salt consumption. Engaging industry to reduce salt in foods was a priority in all countries: Mongolia and Vietnam were establishing voluntary programs, while Argentina and South Africa opted for legislation on salt levels in foods. Ministries of Health, the World Health Organization and researchers were identified as critical players in all countries. Lack of funding and technical capacity/support, absence of reliable local data and changes in leadership were identified as barriers to effective implementation. No country had a comprehensive approach to surveillance or regulation for labelling, and mixed views were expressed about the potential benefits of low sodium salts. Conclusions: Effective scale-up of salt reduction programs in LMICs requires: 1) reliable local data about the main sources of salt; 2) collaborative multi-sectoral implementation; 3) stronger government leadership and regulatory processes; and 4) adequate resources for implementation and monitoring.

Factors Impacting the Uptake of Research into Dietary Sodium Reduction Policies in Five Latin American Countries: A Qualitative Study

“…This is one of the first known studies to examine factors related to the uptake of sodium reduction research into policies and programs in LAC, a topic of interest given the high prevalence of hypertension and CVD, alongside high intakes of sodium in this population. A study conducted a retrospective policy analysis based on reviews of existing reports and semi-structured interviews in 4 LMIC to understand the factors that influenced the implementation of existing salt reduction interventions in each country [ 36 ]. The current study and the policy analysis identified similar factors that impact the research implementation of sodium reduction policies, such as strong leadership and support from the government and other international agencies, as well as adequate resources.…”

National Cross-Sectional Data on Ideal Cardiovascular Health Among Adults in Mongolia in 2019

“…For example, since 2015 the Mongolian national salt reduction strategy has been implemented by ‘creating a social, economic and legal environment that supports salt reduction, including by influencing food supply, increasing partnerships between government and relevant stakeholders, and creating an enabling environment to support improved consumer choices’ [ 33 ]. Part of this initiative included training of chefs, students and employees to implement salt reduction in schools, hospitals, workplaces and kindergartens, and voluntary reductions in salt in bread and bakery products agree on with major companies in 2011 [ 34 ]. However, the average daily salt intake in the 15–69 years-old population was 10.5 gr (more than double the WHO recommendation of <5gr) in 2019, which did not much improve compared to the 2013 survey, 11.1 gr in Mongolia [ 33 ].…”

Review of national nutrition standards with salt-related criteria for publicly funded institutions around the world

“…This is in line with previous research on salt-reduction strategies and highlights the need for additional resources and technical support from international organizations. 20 , 21 Developing and implementing nutrition standards for publicly funded institutions in low- and middle-income countries offers an opportunity to prevent the increase in availability of energy-dense and nutrient-poor packaged and processed foods and ensure healthy food environments in institutions. 3 , 4 As a “best-buy” strategy, 18 there is potential for nutrition standards to have a large health and economic impact, provided standards follow core principles of healthy diets (including reducing salt intake), 22 are easily understandable and enforceable, 23 and are successfully implemented by countries.…”