Multi-sectoral action in non-communicable disease prevention policy development in five African countries.

BACKGROUND: The rise of non-communicable diseases (NCDs) in Africa requires a multi-sectoral action (MSA) in their prevention and control. This study aimed to generate evidence on the extent of MSA application in NCD prevention policy development in five sub-Saharan African countries (Kenya, South Africa, Cameroon, Nigeria and Malawi) focusing on policies around the major NCD risk factors. METHODS: The broader study applied a multiple case study design to capture rich descriptions of policy contents, processes and actors as well as contextual factors related to the policies around the major NCD risk factors at single- and multi-country levels. Data were collected through document reviews and key informant interviews with decision-makers and implementers in various sectors. Further consultations were conducted with NCD experts on MSA application in NCD prevention policies in the region. For this paper, we report on how MSA was applied in the policy process. RESULTS: The findings revealed some degree of application of MSA in NCD prevention policy development in these countries. However, the level of sector engagement varies across different NCD policies, from passive participation to active engagement, and by country. There was higher engagement of sectors in developing tobacco policies across the countries, followed by alcohol policies. Multi-sectoral action for tobacco and to some extent, alcohol, was enabled through established structures at national levels including inter-ministerial and parliamentary committees. More often coordination was enabled through expert or technical working groups driven by the health sectors. The main barriers to multi-sectoral action included lack of awareness by various sectors about their potential contribution, weak political will, coordination complexity and inadequate resources. CONCLUSION: MSA is possible in NCD prevention policy development in African countries. However, the findings illustrate various challenges in bringing sectors together to develop policies to address the increasing NCD burden in the region. Stronger coordination mechanisms with clear guidelines for sector engagement are required for effective MSA in NCD prevention. Such a mechanisms should include approaches for capacity building and resource generation to enable multi-sectoral action in NCD policy formulation, implementation and monitoring of outcomes.

Non-communicable disease prevention policy process in five African countries.

BACKGROUND: The increasing burden of non-communicable diseases (NCDs) in sub-Saharan Africa is causing further burden to the health care systems that are least equipped to deal with the challenge. Countries are developing policies to address major NCD risk factors including tobacco use, unhealthy diets, harmful alcohol consumption and physical inactivity. This paper describes NCD prevention policy development process in five African countries (Kenya, South Africa, Cameroon, Nigeria, Malawi), including the extent to which WHO "best buy" interventions for NCD prevention have been implemented. METHODS: The study applied a multiple case study design, with each country as a separate case study. Data were collected through document reviews and key informant interviews with national-level decision-makers in various sectors. Data were coded and analyzed thematically, guided by Walt and Gilson policy analysis framework that examines the context, content, processes and actors in policy development. RESULTS: Country-level policy process has been relatively slow and uneven. Policy process for tobacco has moved faster, especially in South Africa but was delayed in others. Alcohol policy process has been slow in Nigeria and Malawi. Existing tobacco and alcohol policies address the WHO "best buy" interventions to some extent. Food-security and nutrition policies exist in almost all the countries, but the "best buy" interventions for unhealthy diet have not received adequate attention in all countries except South Africa. Physical activity policies are not well developed in any study countries. All have recently developed NCD strategic plans consistent with WHO global NCD Action Plan but these policies have not been adequately implemented due to inadequate political commitment, inadequate resources and technical capacity as well as industry influence. CONCLUSION: NCD prevention policy process in many African countries has been influenced both by global and local factors. Countries have the will to develop NCD prevention policies but they face implementation gaps and need enhanced country-level commitment to support policy NCD prevention policy development for all risk factors and establish mechanisms to attain better policy outcomes while considering other local contextual factors that may influence policy implementation such as political support, resource allocation and availability of local data for monitoring impacts.

Alcohol policies in Malawi: inclusion of WHO "best buy" interventions and use of multi-sectoral action.

BACKGROUND: Harmful use of alcohol is one of the most common risk factors for Non-Communicable Diseases and other health conditions such as injuries. World Health Organization has identified highly cost-effective interventions for reduction of alcohol consumption at population level, known as "best buy" interventions, which include tax increases, bans on alcohol advertising and restricted access to retailed alcohol. This paper describes the extent of inclusion of alcohol related "best buy" interventions in national policies and also describes the application of multi-sectoral action in the development of alcohol policies in Malawi. METHODS: The study was part of a multi-country research project on Analysis of Non-Communicable Disease Preventive Policies in Africa, which applied a qualitative case study design. Data were collected from thirty-two key informants through interviews. A review of twelve national policy documents that relate to control of harmful use of alcohol was also conducted. Transcripts were coded according to a predefined protocol followed by thematic content analysis. RESULTS: Only three of the twelve national policy documents related to alcohol included at least one "best buy" intervention. Multi-Sectoral Action was only evident in the development process of the latest alcohol policy document, the National Alcohol Policy. Facilitators for multi-sectoral action for alcohol policy formulation included: structured leadership and collaboration, shared concern over the burden of harmful use of alcohol, advocacy efforts by local non-governmental organisations and availability of some dedicated funding. Perceived barriers included financial constraints, high personnel turnover in different government departments, role confusion between sectors and some interference from the alcohol industry. CONCLUSIONS: Malawi's national legislations and policies have inadequate inclusion of the "best buy" interventions for control of harmful use of alcohol. Effective development and implementation of alcohol policies require structured organisation and collaboration of multi-sectoral actors. Sustainable financing mechanisms for the policy development and implementation processes should be considered; and the influence of the alcohol industry should be mitigated.

Correction to: Non-communicable disease prevention policy process in five African countries.

After publication of the article [1], it was noticed that the title has erroneously included 'authors' in the end.

Opportunities and challenges for evidence-informed HIV-noncommunicable disease integrated care policies and programs: lessons from Malawi, South Africa, Swaziland and Kenya.

INTRODUCTION: Countries in sub-Saharan Africa (SSA) are recognizing the growing dual burden of HIV and noncommunicable diseases (NCDs). This article explores the availability, implementation processes, opportunities and challenges for policies and programs for HIV/NCD integration in four SSA countries: Malawi, Kenya, South Africa and Swaziland. METHODS: We conducted a cross-sectional analysis of current policies and programs relating to HIV/NCD care integration from January to April 2017 using document review and expert opinions. The review focussed on availability and content of relevant policy documents and processes towards implementating national HIV/NCD integration policies. RESULTS: All four case study countries had at least one policy document including aspects of HIV/NCD care integration. Apart from South Africa that had a phased nation-wide implementation of a comprehensive integrated chronic disease model, the three other countries - Malawi, Kenya and Swaziland, had either pilot implementations or nation-wide single-disease integration of NCDs and HIV. Opportunities for HIV/NCD integration policies included: presence of overarching health policy documents that recognize the need for integration, and coordinated action by policymakers, researchers and implementers. Evidence gaps for cost-effectiveness, effects of integration on key HIV and NCD outcomes and funding mechanisms for sustained implementation of integrated HIV/NCD care strategies, were among challenges identified. CONCLUSION: Policymakers in Malawi, Kenya, South Africa and Swaziland have considered integration of NCD and HIV care but a lack of robust evidence hampers large-scale implementation of HIV/NCD integration. It is crucial for SSA Ministries of Health and throughout low-and-middle-income countries to utilize existing opportunities and advocate for evidence-informed HIV/NCD integration strategies.

Reframing noncommunicable diseases and injuries for the poorest Malawians: the Malawi National NCDI Poverty Commission.

Noncommunicable diseases and injuries (NCDIs) account for nearly 70% of deaths worldwide, with an estimated 75% of these deaths occurring in low- and middle-income countries. Globally, the burden of disease from noncommunicable diseases (NCDs) is most often caused by the "big 4," namely: diabetes, cardiovascular diseases, cancer, and chronic lung diseases. However, in Malawi, these 4 conditions account for only 29% of the NCDI disease burden. The Malawi National NCDI Poverty Commission was launched in November 2016 and will describe and evaluate the current NCDI situation in Malawi, with a focus on the poorest populations. The National Commission will investigate which NCDIs cause the biggest burden, which are more present in the young, and which interventions are available to avert death and disability from NCDIs in Malawi, particularly among the poorest segments of the population. The evidence gained through the work of this Commission will help inform research, policy, and programme interventions, all through an advocacy lens, as we strive to address the impact of NCDIs among all populations in Malawi.

Building a knowledge translation platform in Malawi to support evidence-informed health policy.

With the support of the World Health Organization's Evidence-Informed Policy Network, knowledge translation platforms have been developed throughout Africa, the Americas, Eastern Europe, and Asia to further evidence-informed national health policy. In this commentary, we discuss the approaches, activities and early lessons learned from the development of a Knowledge Translation Platform in Malawi (KTPMalawi). Through ongoing leadership, as well as financial and administrative support, the Malawi Ministry of Health has strongly signalled its intention to utilize a knowledge translation platform methodology to support evidence-informed national health policy. A unique partnership between Dignitas International, a medical and research non-governmental organization, and the Malawi Ministry of Health, has established KTPMalawi to engage national-level policymakers, researchers and implementers in a coordinated approach to the generation and utilization of health-sector research. Utilizing a methodology developed and tested by knowledge translation platforms across Africa, a stakeholder mapping exercise and initial capacity building workshops were undertaken and a multidisciplinary Steering Committee was formed. This Steering Committee prioritized the development of two initial Communities of Practice to (1) improve data utilization in the pharmaceutical supply chain and (2) improve the screening and treatment of hypertension within HIV-infected populations. Each Community of Practice's mandate is to gather and synthesize the best available global and local evidence and produce evidence briefs for policy that have been used as the primary input into structured deliberative dialogues. While a lack of sustained initial funding slowed its early development, KTPMalawi has greatly benefited from extensive technical support and mentorship by an existing network of global knowledge translation platforms. With the continued support of the Malawi Ministry of Health and the Evidence-Informed Policy Network, KTPMalawi can continue to build on its role in facilitating the use of evidence in the development and refinement of health policy in Malawi.