Navigating institutional complexity in the health sector: lessons from tobacco control in Kenya

Lencucha, Raphael; Magati, Peter; Drope, Jeffrey

doi:10.1093/heapol/czw094

Cited by 9 publications

(15 citation statements)

References 39 publications

(49 reference statements)

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“…This analysis of the experiences of key informants across Bangladesh, Ethiopia, India and Uganda in seeking to implement Article 5.3 is broadly consistent with the challenges of multisectoral coordination identified in the limited empirical literature 6 21 32 36. It highlights the consistency with which engagement with Article 5.3 by government officials beyond health is restricted by limited awareness and understanding, as well as by perceived tensions with wider governance norms and with the mandates of other ministries.…”

Section: Discussionsupporting

confidence: 69%

Advancing whole-of-government approaches to tobacco control: Article 5.3 and the challenge of policy coordination in Bangladesh, Ethiopia, India and Uganda

Barry

Abdullah

Chugh³

et al. 2022

Tob Control

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IntroductionDespite an extensive evidence base on the diverse economic, environmental and social benefits of tobacco control, difficulties in establishing coordinated national approaches remain a defining challenge for Framework Convention on Tobacco Control (FCTC) implementation. Minimising tobacco industry interference is seen as key to effective coordination, and this paper analyses implementation of Article 5.3 guidelines, exploring implications for whole-of-government approaches to tobacco control in Bangladesh, Ethiopia, India and Uganda.MethodsBased on 131 semistructured interviews with government officials and other key stakeholders, we explore barriers and facilitators for promoting: (1) horizontal coordination across health and other policy spheres, and (2) vertical coordination across national and subnational governments on Article 5.3 implementation.ResultsOur analysis identifies common barriers to coordination across diverse geographical contexts and varying approaches to implementation. They highlight broadly shared experiences of limited understanding and engagement beyond health agencies; restricted responsibility and uncertainty amid conflicting mandates; tensions with wider governance practices and norms; limited capacity and authority of coordination mechanisms; and obstacles to vertical coordination across local, state and national governments. Interview data also indicate important opportunities to advance coordination across sectors and government levels, with Article 5.3 measures capable of informing changes in practices, building support in other sectors, allowing for ‘bottom-up’ innovation and being shaped by engagement with civil society.ConclusionSupporting effective implementation of Article 5.3 is key to advancing multisectoral approaches to FCTC implementation and tobacco control’s contributions to global health and sustainable development.

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Section: Discussionsupporting

confidence: 69%

Advancing whole-of-government approaches to tobacco control: Article 5.3 and the challenge of policy coordination in Bangladesh, Ethiopia, India and Uganda

Barry

Abdullah

Chugh³

et al. 2022

Tob Control

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“….it is ready to implement it'. The Government of Kenya established a Tobacco Control Board (TCB) to oversee and advise the Ministry of Health (Lencucha et al 2016c). It advises the Ministry of Health on national policy with regard to the production, manufacturing and use of tobacco and tobacco products, and recommends and participates in the formulation of regulations to be made under the TCA (Musau 2013).…”

Section: Resultsmentioning

confidence: 99%

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

Lencucha

Reddy

Labonté

et al. 2018

Health Policy and Planning

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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.

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“…While implementation of the WHO Framework Convention on Tobacco Control (FCTC) is widely seen as requiring a whole-of-government approach,1 there has been limited empirical research of coordination in multilevel political systems 2 3. Investigation of coordination mechanisms for tobacco control has focused more on horizontal interaction across government sectors4 5 than vertical relationships between different levels of government. Alongside a primary focus on the national level in considering how member states have implemented international obligations under the FCTC,6 7 this has led to a comparative neglect of subnational dynamics in studies of FCTC implementation.…”

Section: Introductionmentioning

confidence: 99%

Understanding the dynamics of notification and implementation of Article 5.3 across India’s states and union territories

Bassi¹,

Ralston

Arora³

et al. 2022

Tob Control

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IntroductionIn federal systems, state and local governments may offer opportunities for innovation in implementing the WHO Framework Convention on Tobacco Control (FCTC). This paper explores the implementation of WHO FCTC Article 5.3 within India’s federal system, examining how its guidelines have been operationalised across states and union territories.MethodsInterviews with officials from government and civil society organisations across key states, and a document review of state government and district administration notifications adopting Article 5.3 guidelines between 2015 and 2019.ResultsThe data reveal subnational leadership in formulating intersectoral committees, which are designed to limit interactions with the tobacco industry, and corresponding measures to reject partnership and conflicts of interest for government officials. There are notable omissions across states and union territories in adoption of key Article 5.3 guidelines; only four districts and state governments refer to regulating aspects of ‘socially responsible’ industry activities, and no notifications include measures to prevent the tobacco industry receiving preferential treatment or requiring that information provided by industry actors be transparent and accountable. Interview data indicate that dynamics of notification across states have been shaped by lesson drawing and the catalytic role of civil society. The adoption of protocols is impacting on the practices of health officials, but there are concerns about engagement by other departments and the regulatory capacity of empowered committees.ConclusionThe spread of state- and district-level policies illustrates opportunities federal structures can provide for accelerating tobacco control. Given significant omissions and policy tensions, there remains a need for national action to build on these innovations, including in revisions to India’s tobacco control legislation.

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Navigating institutional complexity in the health sector: lessons from tobacco control in Kenya

Cited by 9 publications

References 39 publications

Advancing whole-of-government approaches to tobacco control: Article 5.3 and the challenge of policy coordination in Bangladesh, Ethiopia, India and Uganda

Advancing whole-of-government approaches to tobacco control: Article 5.3 and the challenge of policy coordination in Bangladesh, Ethiopia, India and Uganda

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

Understanding the dynamics of notification and implementation of Article 5.3 across India’s states and union territories

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