Analysis of Non-communicable Diseases Prevention Policies in Nigeria

Transcription

1 Analysis of Non-communicable Diseases Prevention Policies in Nigeria FINAL REPORT 2017 Authors: Oladimeji Oladepo (principal investigator), Mojisola Oluwasanu, Opeyemi Abiona

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3 Analysis of Noncommunicable Diseases Prevention Policies in Nigeria FINAL REPORT JUNE 30, 2017 AFRICAN REGIONAL HEALTH EDUCATION CENTRE, DEPARTMENT OF HEALTH PROMOTION AND EDUCATION, FACULTY OF PUBLIC HEALTH, COLLEGE OF MEDICINE, UNIVERSITY OF IBADAN, NIGERIA Authors: Oladimeji Oladepo (principal investigator), Mojisola Oluwasanu, Opeyemi Abiona

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5 Table of Contents List of Tables Abbreviations Preface Acknowledgements Executive Summary and key messages v vi viii ix x 1.0 Introduction Global response to address the burden of NCDs Overview of the study Purpose and objectives Guiding framework Methods Study design Study population Sampling strategy Inclusion criteria Exclusion criteria Data sources and collection procedures Quality of data measures Data management Data analysis Ethical consideration Findings Data sources Document reviews KIIs Policy context Global context Local context 14 Analysis of Non-communicable Diseases Prevention Policies in Nigeria 2017 iii

6 3.2. Development of NCD policies: context, content, process and actors Policy context and history Policy content and best buys addressed Implementation Plan Facilitators to MSA Barriers to MSA Implementation status Tobacco control policy Policy context and history Policy content and best buys addressed Policy process Multi-sectoral involvement Facilitators to MSA Status of Implementation Alcohol control policy Alcohol policy context and history Policy content and best buys addressed Policy process Multi-sectoral involvement Potential facilitators to MSA Implementation plan Challenges to alcohol policy development and implementation Nutrition and unhealthy diet Unhealthy diet policy context and history Global context Local context Policy content and best buys addressed Policy process 42 iv Analysis of Non-communicable Diseases Prevention Policies in Nigeria 2017

7 3.6.4 Multi-sectoral involvement Facilitators to MSA Barriers to MSA Implementation status Physical activity policy Physical activity policy context and history Policy content and best buys addressed Policy process Multi-sectoral involvement Barriers to physical activity policy formulation Implementation status Discussion Gaps in NCD policy Most significant facilitators to NCD policy development Most significant barriers to NCD policy development Limitations Conclusions Recommendations References Annexes 68 Annex 1: Search terms and syntax for document search 70 Annex 2: List of documents reviewed 71 Annex 3: Key informant interview guide 73 Annex 4: Code book 81 Annex 5: Ethical Approval Certificate 83 Analysis of Non-communicable Diseases Prevention Policies in Nigeria 2017 v

8 List of Tables Table 1: WHO best buys 4 Table 2: National policy documents reviewed and year of development 8 Table 3: Types of documents reviewed and key NCD elements addressed 12 Table 4: Number of people identified and a summary of respondent types 12 Table 5: Risk factors and best buy interventions addressed in the NCD Action Plan 18 Table 6: Stakeholders roles in the development of the NCDs Policy and Plan of Action 22 Table 7: Tobacco policies, the best buys addressed and year of development 26 Table 8: Involvement of organizations in the enactment of the 2015 Tobacco Control Act 29 Table 9: Scoring for MSA in tobacco policy formulation 31 Table 10: Alcohol interventions mentioned in other documents 36 Table 11: Scoring for MSA in alcohol policy formulation 36 Table 12: Nutrition policies, the best buys addressed and year of development 42 Table 13: Level of involvement of organizations in the development of the nutrition policies 44 Table 14: Scoring of MSA in unhealthy diet policy formulation. 45 Table 15: Physical activity policies 49 vi Analysis of Non-communicable Diseases Prevention Policies in Nigeria 2017

9 Abbreviations APCON BASICS II BATN BCC CBO CHAI COPD CSO CVD DHS DRNCD FBO FCT FCTC FMOH FRSC GATS GDP GNI GYTS HKI ICAP IDSR IITA Advertising Practitioners Council of Nigeria Basic Support for Institutionalising Child Survival British American Tobacco Nigeria Behavior Change Communication Community-based organization Clinton Health Access Initiative Chronic obstructive pulmonary disease Civil society organization Cardiovascular disease Demographic and Health Surveys Diet-related non-communicable diseases Faith-based organization Federal Capital Territory Framework Convention on Tobacco Control Federal Ministry of Health Federal Road Safety Commission Global Adult Tobacco Survey Gross domestic product Gross national income Global Youth Tobacco Survey Helen Keller International International Center for Alcohol Policies Integrated Disease Surveillance Response International Institute of Tropical Agriculture Analysis of Non-communicable Diseases Prevention Policies in Nigeria 2017 vii

10 JHU/HCP KII LMIC MDAs MDG M&E MIS MSA NAFDAC NCD NCFN NDLEA NFNP NGOs NPHCDA NSHDP NTCC PCN PHC SON UNGA UNICEF USAID WHO Johns Hopkins University/Health Communication Project Key informant interviews Low and middle-income countries Ministries/departments/agencies Millennium development goal Monitoring and evaluation Management information system Multi-sectoral action National Agency for Food and Drug Administration and Control Non-communicable disease National Committee on Food and Nutrition National Drug Law Enforcement Agency National Food and Nutrition Policy Non-governmental organizations National Primary Health Care Development Agency National Strategic Health Development Plan National Tobacco Control Committee Pharmacists Council of Nigeria Primary health care Standard Organization of Nigeria United Nations General Assembly United Nations Children Funds United States Agency for International Development World Health Organization viii Analysis of Non-communicable Diseases Prevention Policies in Nigeria 2017

11 Preface The report summarizes the findings of the Nigerian component of a multi-country research project entitled Analysis of Non-communicable Diseases Prevention Policies in Africa (ANPPA). The study was conducted by the African Regional Health Education Centre (ARHEC) of the Department of Health Promotion and Education, Faculty of Public Health, College of Medicine, University of Ibadan, Nigeria and funding was provided through the African Population Health Research Center (APHRC), Kenya by International Development Research Center (IDRC), Canada. The opinions expressed herein are those of the authors and do not necessarily reflect the views of the APHRC or the IDRC. Additional information about the ANPPA project in Nigeria can be obtained from the ARHEC Office, of the Department of Health Promotion and Education, Faculty of Public Health, College of Medicine, University of Ibadan, Nigeria. Analysis of Non-communicable Diseases Prevention Policies in Nigeria 2017 ix

12 Acknowledgements This report was prepared by Professor Oladimeji Oladepo, Mojisola Oluwasanu and Opeyemi Oladunni. The research was funded by the International Development Research Center (IDRC), Canada, through a fellowship offered by the African Population Health Research Center (APHRC), Kenya on the Analysis of NCDs Prevention Policies in Africa (ANPPA) project. The authors thank Dr. Catherine Kyobutungi, Dr. Pamela Juma, Professor Jennifer Wisdom, Dr. Shukri F. Mohamed and Dr. Samuel Oti for their technical support during the study. The cooperation of former and current coordinators of the non-communicable diseases division of the Federal Ministry of Health, Abuja Dr. Tony Nsoro and Dr Nnnena Ezeigwe, respectively and all officials of the health and non-health sectors who participated in the study is also appreciated. x Analysis of Non-communicable Diseases Prevention Policies in Nigeria 2017

13 Executive summary and key messages Non-communicable diseases (NCDs), mainly cardiovascular diseases, cancers, chronic respiratory diseases and diabetes, are leading threats to human health and development in Nigeria. Africa s most populous country contributes substantially to the global burden. Four modifiable risk factors are linked with these diseases, and primary prevention strategies are key to tackling them. The World Health Organization (WHO) developed the Global Action Plan for the Prevention and Control of NCDs, which recommends multi-sectoral actions (MSA) as an overarching principle to underpin formulation and implementation of NCD policies. The document also stresses the need to integrate highly cost-effective, feasible and culturally acceptable interventions termed best buys into country-level NCD prevention, control policies and plans, to accelerate results in terms of lives saved, diseases prevented, and costs averted. Nigeria developed some NCD policies in line with this global recommendation. However, there is a dearth of information on the extent to which MSA was used in the formulation, implementation, and integration of the best buy interventions in these policies. For this reason, this study aims to generate evidence on the application of MSA to the development of policies related to NCD prevention best buys in Nigeria. Specifically, the study: assessed NCD best buy implementation, its barriers and facilitators; generated evidence on how MSA is used in formulating policies for NCD best buy implementation in different contexts, with an emphasis on the population-based interventions in Nigeria; and provides information to policy and decision-makers on how to design and implement the NCD best buys. This study adopted a descriptive case study design and applied the Walt and Gilson framework of policy analysis as its guide. A three-prong approach was used in collecting data: first, a scoping review using the Google search engine in conjunction with the electronic databases PubMed, Science Direct, and Google Scholar identified published articles and policy documents written in English with no date restrictions. Second, published and unpublished policy documents unavailable online were obtained from relevant government institutions. Both approaches yielded 17 policy documents, 26 articles, media publications, and national/international reports pertinent to the study s focus, which were thematically reviewed in line with the study objectives. Third, indepth interviews using pre-tested guides were conducted with 44 technocrats and policy makers who either participated, or would have participated, in the formulation of NCD prevention policies. The qualitative data generated was transcribed, coded, and analyzed using NVivo qualitative data analysis software version 10. Ethical approval for the study was obtained in 2013 from University of Ibadan/University College Hospital Ethical Review Committee, Nigeria. Informed and voluntary consent were obtained from all participants. Tobacco use topped the list with 18 published and unpublished NCD-related policy documents reviewed, followed by harmful alcohol use. Significant variation on the four major NCD behavioral risk factors exists in the policy documents. The National Policy and Strategic Plan of Action on NCDs is the only stand-alone overarching policy document for NCD prevention and control in Nigeria. Tobacco use is the only modifiable risk factor with a comprehensive set of policy actions that align with global recommendations. All the best buy tobacco interventions were adopted and backed by an act of the National Assembly. The national NCD policy and Federal Road Safety Corps (FRSC) Act only addresses one best buy intervention for alcohol, restricted access to alcohol. There is no comprehensive policy to regulate alcohol marketing, advertising or availability. Policies to promote healthy diets exist, Analysis of Non-communicable Diseases Prevention Policies in Nigeria 2017 xi

14 but incorporation of all best buy interventions is found only in the national NCD policy. There are currently no acts to regulate salt and trans-fat content in manufactured foods, and most proposed actions are largely only educational. The high prevalence of insufficient physical activity in Nigeria notwithstanding, there is no focused policy. Despite the relative importance of MSA, its impact on policy formulation is low, except for two risk factors, tobacco use and unhealthy diet. This indicates that some relevant sectors were not involved in the formulation process. The most important facilitators affecting NCD policy development are Nigeria s WHO membership, which commits the government to a series of resolutions; the participation of presidents and other high-level officials in UN high-level meetings; epidemiological data, especially from global studies displaying the burden of NCDs; and strong advocacy by civil society organizations. Several barriers constrain NCD policy development process and implementation; major ones include: overdependence on donor funding; low or non-existent government budgetary allocation to support the process; relatively low political priority compared with other health challenges in Nigeria; and industry influence. Others include poor understanding of how to implement MSA, poor stakeholder knowledge of sectors roles and contributions to NCD prevention, extensive multi-stakeholder and participatory processes; and conflict between government ministries to assume leadership. These findings were shared with several types of policy makers at different fora at national and local levels. Not all NCD policies in Nigeria engrain the principles of MSA and best buy interventions in their formulation, and funding constraint is apparent. The neglect of these challenges could increase the NCD burden in Nigeria. Urgent development of innovative approaches to confront these challenges is needed to avert the consequences of future high-level NCD morbidity and mortality. xii Analysis of Non-communicable Diseases Prevention Policies in Nigeria 2017

15 Introduction 1.0 Introduction

16 The four main non-communicable diseases (NCDs) heart diseases and stroke, chronic obstructive pulmonary diseases (COPD), type 2 diabetes, and cancers are a leading threat to human health and development (World Health Organization 2014a). Nigeria is the most populous African country, with a population of 187 million (Popuation Reference Bureau 2016) and contributes substantially to the global burden. These four NCDs are strongly linked to changing behavioral practices, and four modifiable behavioral risk factors tobacco use, unhealthy diet, harmful use of alcohol, and insufficient physical activity reflect a pervasive aspect of economic transition, globalization, rapid urbanization and 21st-century lifestyles (World Health Organization 2013). All four behavioral risk factors are preventable. According to WHO 2010, more than 80% of cardiovascular diseases and stroke, COPD, type 2 diabetes and more than a third of cancers are preventable by eliminating the four shared behavioral risk factors. The prevalence of these four behavioral risk factors in Nigeria makes them issues of public health importance. According to the 2012 GATS, 5.6% of Nigerian adults currently use tobacco products (10.0% men, 1.1% women; 4.5 million adults); 3.9% smoke tobacco (7.3% men, 0.4% women; 3.1 million adults); and smokeless tobacco products were used by 1.9% of adults (2.9% men and 0.9% women; 1.6 million) (FMOH 2012). Moreover, the FMOH Global Youth Tobacco Survey (GYTS) country report 2008 indicated the potential for the number of Nigerian smokers to rapidly increase as smoking experimentation among Nigerian children aged ranged from 3.6% to 16.2%, depending on the state (Ekanem 2008). An increasing consumption of alcohol is reported, with annual projected estimate for adult per capita consumption of pure alcohol at liters (World Health Organization 2010a). Nigeria ranks 27th among countries with the highest per capita consumption of alcohol globally (World Health Organization, 2014). The age-standardized prevalence of heavy episodic drinking within 30 days is estimated at 7% (12% males; 1.9% females) (World Health Organization 2014b). In respect to unhealthy diets, street foods and fast foods contribute between 53.2% to 92.6% of the total nutrient intake of people aged in Oyo state, making them primary consumers of these foods (Akinyele 1998). A recent study examining the average salt content in 100 samples of retail bread in Enugu state showed a salt content of 1.36g per 100g, which means that consuming six slices of bread equates to a daily sodium intake of 3.33g of salt from bread alone against the recommended dietary allowance of 5g for normotensive adults (Nwanguma & Okorie 2013). According to Ifenkwe (2012), Nigeria has more than nine food laws, although the implementation of these laws is poor. Insufficient physical activity is prevalent in Nigeria. A recent study (Adegoke & Oyeyemi 2011) indicated that 41% of the study population were insufficiently physical active. According to the 2014 Global Status Report on NCDs, the crude adjusted estimates of the national prevalence of insufficient physical activity was 19.8% (17.7% males; 21.9% females) (World Health Organization 2014a). The high estimated prevalence of NCD biomarkers in the country as determinants of the four major NCDs is of concern. According to the WHO 2010 Global Status Report on NCDs, the biomarkers prevalent in Nigeria were: raised blood pressure (42.8%); raised blood glucose (8.5%), raised cholesterol (16.1%), and overweight and obesity (26.8% and 6.5% respectively) (World Health Organization 2010a). Nigeria s high prevalence of both behavioral and physiological risk factors remains a cause of grave concern and continues to impact NCD-related morbidity and mortality. A 2003 surveillance study conducted in Lagos state showed an overall prevalence of hypertension of 18.2% (Onyemelukwe 2003). A recent systematic review of studies conducted in Nigeria found that the crude prevalence of hypertension ranged from 2.1% to 47.2%, and a higher prevalence was found among men and urban dwellers (Akinlua et al ). The NCD survey showed that diabetes mellitus accounted for an overall prevalence of 2.7% among Nigerians over age 2 Analysis of Non-communicable Diseases Prevention Policies in Nigeria 2017

17 15, but the report of the International Diabetes Federation (2014) disclosed that diabetes affects more than three million Nigerians with a prevalence of 4.6%, which nearly translates into a twofold increase. New cases of cancer are reported annually at 102,100 while a five-year prevalence is 232,000 (International Agency for Cancer Research and World Heath Organization 2012). NCD-related mortality is a major burden. Nigeria contributes significantly to the global burden of NCDs with an estimated 792,600 NCDs related deaths in The 2014 World Health Organization Global Status report on NCDs showed that the percentage of NCD deaths occurring under age 70 years in Nigerian men and women was 76.7% and 74.6%, respectively (World Health Organization 2014a). Akinboboye et al., (2003) reported that cardiovascular diseases accounted for one-tenth of deaths (Akinboboye, Idris, Akinboboye, and Akinkugbe 2003). Diabetes-related deaths among people aged in 2014 were 105, (International Diabetes Federation 2014). The age standardized death rate per 100,000 for men was for cancers, 40.1 for COPD, for cardiovascular diseases and 41.9 for diabetes. For women, the age standardized death rate per 100,000 was 97 for cancers, 34 for COPD, for cardiovascular diseases and 51.4 for diabetes (World Health Organization 2014a). Given the high prevalence of behavioral risk factors, high morbidity and mortality of the four major NCDs, coupled with poor policy response and weak health systems unable to cope with the double burden of infectious and chronic diseases, the Nigerian government must act urgently to strengthen NCD policies and programs. 1.1 Global response to address the burden of NCDs Realising that primary prevention strategies must be at the forefront of the global fight to reduce prevalence rates, the World Health Organization developed a Action Plan for the Global Strategy for the Prevention and Control of NCDs (World Health Organization 2008a). The first objective outlined is the need to raise the priority accorded to NCDs in development work at global and national levels, integrating prevention and control of such diseases into policies across all government departments, including non-health sectors (WHO 2008a). As a followup to the action points, the Sixty-sixth World Health Assembly in May 2013 adopted the Global Action Plan for the Prevention and Control of NCDs for the period (World Health Organization 2013). This plan states that national policies in sectors other than health have a major bearing on the risk factors for NCDs, and that health gains can be achieved much more readily by influencing public policies in sectors such as trade, taxation, education, agriculture, urban development, and food and pharmaceutical production than by changing health policies alone. This underlying principle, also known as the multi-sectoral action (MSA), is defined as actions undertaken by sectors outside the health sector, possibly, but not necessarily, in collaboration with the health sector, on health or health-related outcomes or the determinants of health or health equity (Public Health Agency of Canada and World Health Organization. 2008). It is the foundation of the global NCD prevention agenda, requesting all countries to establish or strengthen existing policies and plans for NCD prevention and control as an integral part of their national health policy using the MSA principle. The global epidemic of NCDs can be reversed through modest investments in interventions termed best buy interventions, which were tested, proven to work, and cost-effective. When applied, the best buy interventions have the greatest benefit in cost-effectively reducing population-level risk (see Table 1 for a list). However, the extent of MSA integration and best buys that address the four major behavioral risk factors in existing Nigerian NCD policies is unclear. Therefore this study focused on the best buys for these four modifiable, behavioral risk factors. Analysis of Non-communicable Diseases Prevention Policies in Nigeria

18 The World Health Organization 2013 Global Action Plan for the Prevention and Control of NCDs recommended the whole-of-government approach in tackling NCDs and their behavioral risk factors (World Health Organization 2013), which mean public service agencies in different sectors must work together in an integrated government response to achieve a shared goal. The global NCD strategy also recommends the whole-of-government approach address the social determinants of health, as it influences population risk and individual behaviors. These determinants lie beyond the purview of the health sector, and several non-health sectors (such as agriculture, education, urban planning, and transportation) play a role in shaping the NCD environment (Juma et al. 2016). In line with these key principles, the team identified relevant sectors with a potential link and influence on each of behavioral risk factor (aside from the health sector) and this was used in selecting respondents for interview. This study examined NCD prevention policies in Nigeria from the perspective of MSA and best buy interventions. Table 1: WHO best buys Risk factor/disease Policy interventions Tobacco use Tax increases Smoke-free indoor workplaces and public places Bans on tobacco advertising, promotion, and sponsorship Health information and warnings Harmful alcohol use Tax increases Bans on alcohol advertising Restricted access to retailed alcohol Unhealthy diet and physical inactivity Cardiovascular disease (CVD) and diabetes Reduced salt intake in food Replacement of trans fat with polyunsaturated fat Public awareness through mass media on diet and physical activity Counseling and multi-drug therapy for people with a high risk of developing heart attacks and strokes (including those with established CVD) Treatment of heart attacks with aspirin Cancer Hepatitis B immunization to prevent liver cancer Screening and treatment of pre-cancerous lesions to prevent cervical cancer Source: (World Health Organization 2011a) 1.2. Overview of the study Purpose and objectives This study is part of a broader study implemented in six countries (Kenya, Malawi, South Africa, Cameroon, Malawi and Togo) the long-term goal of which is to promote MSA by providing evidence on the effectiveness of these approaches in the implementation of best buys in sub- Saharan Africa. The short-term goal is to generate evidence from at least six countries while building capacity for research in the area of MSA. This report focuses on the Nigerian case study. The purpose of the Nigerian case study was to generate evidence on how MSA informs policies related to the implementation of NCD prevention best buys in Nigeria. The specific objectives were to: (1) conduct an in-depth assessment on the state of implementation of the NCD best buys and of the barriers to their full implementation; 4 (2) generate robust evidence on the extent to which and how MSA is used in the formulation of policies for the implementation of the NCD best buys in different contexts, with an emphasis on the population-based interventions in Nigeria; and Analysis of Non-communicable Diseases Prevention Policies in Nigeria 2017

19 (3) provide robust evidence to policy and decision-makers that informs the design and implementation of the NCD best buys Guiding framework The Walt and Gilson framework guided this study. It acknowledges the non-linearity of the policy process with a focus on four policy factors: (i) policy content in respect of how the NCD problems are formed and framed; how they become issues on the policy agenda; policy objectives, programs, actions, targets and resources required; (ii) the policy actors and how they influence policy-making, and under what conditions; (iii) the processes used in developing and implementing the policy; and (iv) the context that influences the policy-making, such as demographic and epidemiological change, processes of social and economic change, economic and financial policy, politics and the political regime, and external factors (Juma et al. 2016; Walt & Gilson 1994). Analysis of Non-communicable Diseases Prevention Policies in Nigeria

20 Methods 2.0 Methods

21 2.1. Study design The study adopted a descriptive, case study design that involved integrating multiple sources of data to describe and explain NCD prevention policies in Nigeria. The case study design is a preferred strategy: how and why questions are posed with focus on historical or contemporary phenomena within real-life contexts, which the investigator has little or no control over (Yin 2013). This particular design is suitable as the aim of the research is to provide an in-depth understanding of MSA in NCD prevention-related policy actions (that might or might not involve MSA); why they were developed; how they were developed; and how they were implemented (Juma et al ). The design is appropriate to answer the questions of events and processes we, the researchers, have little control over. Qualitative methods specifically document reviews and in-depth interviews were used for data collection Study population The study population for the key informant interview included policy actors and technocrats from various sectors who either participated, or should have participated, in the NCD policy formulation and implementation of NCD prevention actions related to the best buys. The sectors included the ministries of Health, Finance, Youth and Sport, Womens Affairs, Information, Education, Labour, Trade and Commerce, Justice, the National Agency for Food and Drug Administration and Control, and the legislature. Others were interviewed from industries, non-governmental organizations (NGOs) and professional bodies Sampling strategy We identified 44 policy actors from different sectors such as ministries, organizations or groups who participated, or who should have participated, in the development and implementation of NCD prevention policies related to the best buys (details in appendix I). Purposive sampling was employed in selecting the policy actors based on relative importance and (potential) roles in formulation and implementation of the national NCD prevention policies. In addition, the snowballing technique was used to identify additional respondents during interviews with the index key informants. Using purposive sampling ensured maximum variability across relevant units Inclusion criteria We sampled key policy actors who either participated, or would have participated, in NCD policy formulation or implementation of any of the four identified risk factors, and others identified by index key informants Exclusion criteria Any person who does not have a pivotal or potential role in the formulation or implementation of national NCD prevention policies Those unwilling to answer or participate in the interviews 2.4. Data sources and collection procedures A mixed-method approach was used to collect data for this case study. It consisted of the following: Analysis of Non-communicable Diseases Prevention Policies in Nigeria

22 i. Document reviews A scoping review of three online databases (PubMed, Science direct, Google Scholar) and a search engine (Google) using search syntax (details in appendix II) identified published articles and policy documents written in English with no date restrictions. Relevant government institutions provided policy documents that could not be accessed online. The search yielded 17 national policy documents and 26 articles and reports (appendix III) relevant to the policy formulation process. Other identified documents included administrative data and archival records, such as the Nigeria GATS Report, 2010 and 2014 WHO Global Status Report on NCDs, among others. The desk review of 17 national policy documents was conducted using an inventory extraction tool (specifically, a Microsoft Excel spreadsheet) with variables such as the document type, author, year, objectives, strategies, and NCD policy element addressed, with emphasis on the best buys. Each policy document was reviewed and information aligning with these variables was extracted to populate the inventory extraction tool. The national policy documents are listed in Table 2. A detailed list of documents reviewed in Appendix III): Table 2: National policy documents reviewed and year of development Risk factors addressed National policy documents Year of development Type of policy document Tobacco use Nigeria Tobacco (Control) Act 1990 CAP.T Legislative policy National Tobacco Control Act Legislative policy Standards for tobacco and tobacco products 2014 Non-legislative policy Harmful alcohol use Federal Road Safety Commission Act Legislative policy Unhealthy diets National Policy on Food and Nutrition in Nigeria 2001 National Plan of Action on Food and Nutrition in Nigeria 2005 National Nutritional Guideline on NCD Prevention, Control and Management 2014 Health Sector Component of National Food and Nutrition Policy National Strategic Plan of Action for Nutrition ( ) Fats and Oils Regulations 2005 Food Grade (Table or Cooking) Salt Regulations 2005 Fruit Juice and Nectar Regulations Non-legislative policy Non-legislative policy Guidelines Non-legislative policy Guidelines Guidelines Guidelines Physical inactivity Other crosscutting policy documents National Sports Policy Non-legislative policy Health Promotion Policy 2006 National School Health Policy 2006 School Health Policy Implementation Plan Policy and Strategic Plan of Action on NCDs 2015 National Strategic Plan of Action on Prevention and Control of NCDs Non-legislative policy Non-legislative policy Non-legislative policy Non-legislative policy 8 Analysis of Non-communicable Diseases Prevention Policies in Nigeria 2017

23 ii. Key informant interviews (KII) A qualitative guide developed by the ANPPA team and pre-tested in Nigeria was used to conduct 44 KII exploring policy objectives; governance structures; actors and their roles in policy-making; decision-making processes for actions taken or not taken; and unintended actions and factors (internal and external) that influence policy-making and implementation; such as changes in sector structures and financing mechanisms (details in appendix IV). iii. Policy engagement meetings As part of the preparatory activities preceding the case study, policy engagement meetings were held with the participating sectors to introduce the purpose of the study and solicit their support for the data collection processes. Subsequently, a meeting was held with sector representatives to validate key findings and obtain additional information in line with the study objectives. iv. Pretesting of tools Tool testing prior to commencement of data collection was conducted in Nassarawa because the state has staff at the government ministries as well as donor agencies and allied organizations who could serve as proxies. The pretest process ensured the tool construct had validity as well as provided an opportunity to train and enhance the competencies of the study interviewers with regards to the study objectives and the implementation of the research activities. The selection and training of interviewers in Federal Capital Territory (FCT) Abuja and Nassarawa was very apt for the field testing of tools due to its proximity to the FCT Quality of data measures Data quality checks were ensured throughout data collection and interview transcription. Research assistants were closely supervised to ensure collected data was of optimal quality and the key informants were interviewed. The research team listened to interviews as soon as they were conducted to identify errors/discrepancies. Some respondents were contacted to verify the completed information s accuracy. The research team read several transcripts to get acquainted with data and identify incomplete sections, typographical errors, formatting errors, and slang language. The pre-assigned codes were entered into Nvivo to ensure consistency (details in appendix V) Data management All interview audio recordings were transcribed verbatim. The transcribed data was cleaned and saved in Microsoft Word by the research team. Identification codes were assigned to all individual records including audiotapes, transcripts, and demographic information, which was stored on a password-protected computer. Copies were backed up on a cloud storage system Data analysis Information was manually extracted and entered into a matrix. The display data shows the policy name, year of publication, names of sectors involved, extent of MSA integration and type of best buy intervention present. Transcripts were imported into Nvivo 10 for data coding, which used the pre-determined coding frame prepared by ANPPA. Data was analyzed using content guided by research Analysis of Non-communicable Diseases Prevention Policies in Nigeria

24 questions. Codes were categorized depending on how codes related, linked and organized data. Three research team members analyzed and interpreted the data to ensure the accuracy of theme identification, understanding of concept, causal linkages, making inferences, attaching meanings, and dealing with contradictory information cases. Emerging categories based on initial analysis framework, such as policy context, policy process, policy actors, MSA, etc., were analyzed and memorable expressions pulled and presented Ethical consideration Ethical approval for the study was obtained from University of Ibadan/University College Hospital Ethical Review Committee, Nigeria in 2013 (details in appendix VI). The study was conducted based on ethical guidelines and principles of confidentiality, non-malfeasance, beneficence and voluntariness. Consent forms providing information on study objectives and plans for data use and dissemination were provided to all participants prior to interviews in order to facilitate voluntary participation. These signed consent forms were a prerequisite for the KIIs. Respondents were informed of potential benefits and risks and their rights to decline questions. They were assured that potential respondents who refused to participate in the study would not be victimized or subject to any form of harassment. Interviews were conducted in settings that ensured respondent privacy. Data confidentiality was ensured at all stages: all identifiers were removed and the data was stored on a password-secured hard drive. Copies were backed up in the research project s shared drop box with password protection. The research team ensured limited access to digital responses of the participants. Results were presented using codes rather than identifiers. 10 Analysis of Non-communicable Diseases Prevention Policies in Nigeria 2017

25 Findings 3.0 Findings

26 3.1 Data sources Document reviews We reviewed 43 articles comprising national acts, regulations or guidelines, and media reports. Details are outlined in Annex 3. The number of documents identified for each of the four risk factors is detailed in Table 3. The number and types of respondents for KII is shown in Table 4. Table 3: Types of documents reviewed and key NCD elements addressed Document type Total number National policies, acts, regulations or guidelines 17 Published journal articles 13 Reports from international/national organizations 9 Media reports 4 Total 43 Key NCD elements addressed Number of documents Tobacco use 18 Harmful use of alcohol 14 Unhealthy diet 11 Insufficient physical activity Key Informant Interview We intereviewed 44 policy actors representing different sectors, such as government ministries, international organizations, professional bodies, NGOs, etc. (details in appendix I). Table 4: Number of people identified and a summary of respondent types Respondent type Government sectors Health (9) Education (2) Trade and Investment (1) Labour (1) Justice (1) Information (2) Finance (2) Youth and Sports (2) Women Affairs (1) Food, Drug Administration and Control (2) Legislature (1) Private not-for-profit/ngos/csos/fbos/cbos Private for profit Research/academic institutions (9) 9 International organizations (1) 1 Bilateral organizations NCD associations/alliance (3) 3 Professional bodies/associations (3) 3 Donors Total number Analysis of Non-communicable Diseases Prevention Policies in Nigeria 2017

27 NGOs/civil society (1) 1 Hospitality/food industry (2) 2 Religious body (1) 1 Total Policy context This section presents an overview of the global and local contextual factors that influenced NCDs and NCD prevention policy development in Nigeria. It first describes the influence of the global context; followed by the Nigerian context, including economic, political, socio cultural, epidemiological and health systems. It then explaines the major national policies and factors that enhanced or hindered the policy formulation and implementation processes Global context Major global events shaping the NCD policy formulation context include the rising burden of NCDs and their links to achievement of millennium development goals (MDGs) and the sustainable development goals (World Health Organization 2015a). The increasing realization the role NCDs play in socioeconomic development, environmental sustainability, and poverty alleviation informed the need for an international discussion on the need for national responses to control and prevent NCDs. In this regard, several WHO assemblies and the UN high-level meetings were held, resulting in resolutions that member-countries are expected to ratify and adopt. Such meetings include: the Framework Convention on Tobacco Control (FCTC) 2003; Strategies to Reduce the Harmful Use of Alcohol Resolution WHA61.4; Global Strategy on Diet, Physical Activity and Health, World Health Assembly Resolution WHA 57.17; Regional WHA NCD Strategy for Africa Region FR/RC50/10 April 2011; and UNGA 66/2 September 2011 (Federal Ministry of Health [FMOH] 2013). While Nigeria participated in the above meetings, two other key global events were significant to NCD policy making. First is the Global Strategy for the Prevention and Control of NCDs (World Health Organization 2008a), which articulates actions to tackle the growing public health burden imposed by NCDs, and recommends actions for completion or initiation by the WHO secretariat and member-states and international agencies (World Health Organization 2008a). It also outlines the importance of member-states to establish and strengthen national policies and plans, as well as national capacity, leadership, governance, MSA and partnerships, to accelerate country responses for NCD prevention and control (World Health Organization 2008a). A follow-up meeting on the Global Action Plan for the Prevention and Control of NCDs commits governments to a series of MSAs and provides guidelines and policy options that member countries are expected to collectively implement between 2013 and 2020 to the attain the nine global NCD targets by 2025 (World Health Organization 2013). Findings revealed that these global contexts influence national policy making through Nigeria s participation. Political interest in NCDs was raised and NCD awareness among some Civil Society organizations (CSOs) catalyzed them to become advocates for tobacco control as exemplified in the following quote: It has to do with reactions of civil society organizations towards that aspect [Tobacco Control], coupled with the United Nations resolutions. [Official FMoH, code 012]. Through this broadened political consciousness, FCTC was ratified and signed in 2004 and 2005, respectively. While this strength is acknowledged, significant weaknesses exist. For instance, the passage of the FCTC bill into an act took 10 years and several failed attempts. Despite actions aimed at increasing the level of political interest and priority for other NCD risk factors, they remained largely unaddressed until the 2011 UN political declaration, which stimulated action towards developing a new comprehensive NCD prevention policy. The 2011 UN high-level meeting Analysis of Non-communicable Diseases Prevention Policies in Nigeria

28 on NCDs, in which the ex-president Dr. Goodluck Jonathan led the Nigerian delegation and presented the country s position paper on NCDs, also influenced the NCD policy formulation and implementation in Nigeria. Consequently, participation in this meeting catalyzed the NCD policy development process, as illustrated in the following quote: I remember when I came in newly in 2011, the UN General Assembly for that year was basically on NCDs the president had to present [Nigeria s position paper on NCDs] and then it dawned on [the Minister of Health] that he had actually not, we had not, done much on NCDs you know the minister started talking about NCDs, and then in that process, you know, we were like, okay, these policies are now having a new push, so I think the push started from [Official, FMOH, code 001]. This agrees with the observation that an important outcome of the meeting is the strong, high-level political support for tackling the NCD crisis within countries (Beaglehole, Bonita and Horton 2011). This political support is reflected in strong commitment of the government of Nigeria leading to the development of the health sector-driven maiden edition of the National Policy on NCDs, with a draft online publication in 2013 (FMOH 2013). The political priority for NCDs increased following the 2011 meeting (Chinenye, Oputa and Oko-Jaja 2014). A third global factor that influenced the Nigerian NCD policy process was the continuous need for government officials to provide status updates, either on the level of formulation, or implementation of NCD prevention policies at international meetings, including the potnential embarrassment resulting from exposing Nigeria s inadequacies at these forums: Another reason I will say why they are pushing, rather, why government is pushing these policies hard, is most of the time for international meetings you have to give your country implementation status, and Nigeria will not have anything to present, so it is embarrassing when you go out. Nigeria is considered [the] giant of Africa, and you don t have anything to present, smaller African countries are presenting documents... I think that is one of the reasons. [Official, FMOH, Code 002] Local context Nigeria is a political influencer in Africa and a leading exporter of crude oil, which accounts for more than 90% of the export value the gross domestic product (GDP) per capita for 2012 is US$1,555 and the gross national income (GNI) per capita for 2012 is US$2,420. The human development index in Nigeria in 2013 was 0.471, which shows that poverty level is high; this significantly drives and sustains NCDs (FMOH 2013). Despite the country s substantial financial resources, the priority accorded NCD prevention and control is as exemplified in the content of the recent Nigerian National Strategic Health Development Plan (NSHDP) ( ), which is the overarching framework for health development in Nigeria (FMOH 2010). Although the 36 state governors and the FCT minister are signatories and affirmed their commitment to improve the health status of Nigerians through the implementation the document, with an estimated cost of US$ billion over a six-year period ( ) (FMOH 2010), a critical analysis shows significant gaps in respect to the poor prioritization and articulation of NCD actions for prevention and treatment, with a lopsided emphasis on communicable and maternal health issues. The health systems in Nigeria (tertiary, secondary and primary) have pivotal roles to play in NCD prevention, but currently have weak capacities (infrastructure, skilled manpower, and funds) to implement strategies outlined in the national NCD prevention and control policy. The primary health care system is disempowered to coordinate the implementation of NCD prevention strategies using the MSA approach due to the lack of specific policy backing to do so. In this context, opportunities for reducing NCDs are lost. 14 Analysis of Non-communicable Diseases Prevention Policies in Nigeria 2017

29 Prior the United Nations General Assembly on NCDs in 2011, there were fragmented responses for NCD prevention and control, depending on the interest of the FMOH s political leadership. Concerted efforts were made by the FMOH to document the burden of NCDs with the national surveys on NCDs in (Onyemelukwe 2003). This effort was championed by Professor Akinkugbe, an emeritus professor of medicine. The epidemiological findings of the 1991 NCD survey revealed a growing NCD burdens and risk factors among Nigerians, which resulted in government actions such as the integration of NCDs into the Primary Health Care (PHC), domestication process for the WHO FCTC, and integration of NCDs into the Integrated Disease Surveillance Response (IDSR) system of reporting in recognition of the huge contribution of NCDs to the burden of disease in Nigeria. Furthermore, the Federal Government appointed the Expert Committee to formulate goals and policy for prevention and institutional manpower development, and to undertake national survey researches to determine prevalence of NCDs and their risk factors (FMOH 2013). However, the low political priority to commence and sustain actions for NCD prevention at national state and local government levels was a major factor undermining efforts to make NCD prevention and control a government priority. In light of broader policies, the Nigerian constitution does not have content relating to NCD prevention. On the contrary, the Nigerian National Health Act specifically states that the National Council of Health is to facilitate and promote the provision of health services for the management, prevention and control of communicable and NCDs (Federal Government of Nigeria 2014). The act also specifies that under the establishment of health research, proposals and protocols conducted by relevant institutions and agencies or establishment will promote health and contribute to the prevention of communicable and NCDs (Federal Government of Nigeria 2014). However, it is difficult to assess how far these policy strands are being meticulously implemented Development of NCD policies: context, content, process and actors This section outlines the actual policies focusing on NCD best buys. For each risk factor we describe the policy context and historical background, policy content, the policy development process, and MSA use in policy formulation and implementation. The first section presents the analysis of the 2013 National Policy and Strategic Plan of Action on Prevention and Control of NCDs and the 2015 National Strategic Plan of Action on Prevention and Control of NCDs, the overarching NCD prevention policy in Nigeria, which has policy actions for all the four major modifiable risk factors. We then present policies relating to the four risk factors: tobacco use, harmful use of alcohol, unhealthy diet and insufficient physical activity. National Policy and Strategic Plan of Action on Non-communicable Diseases in Nigeria: Nigeria s overarching NCD prevention policy Policy context and history The 2013 National Policy and Strategic Plan of Action on NCDs is the overarching policy guideline for NCD prevention and control in Nigeria (FMOH 2013). The vision statement of the policy is A healthy Nigerian population with reduced burden of NCDs and enhanced quality of life for socio-economic development. The principles enshrined in the National Policy and Strategic Plan of Action on NCDs are: ensuring the protection of the rights of individuals and communities; ensuring gender equity; acknowledging the existence of cultural and religious sensitivities; the use of evidence-based information and best practices; encouraging a consultative, participatory and multi-sectoral approach; and strengthening partnerships with stakeholders and development partners (FMOH 2013). Nigeria has no comprehensive NCD prevention and control policy as a guide, so its participation at the UNGA 2011 high-level meeting, and the subsequent mandate for Analysis of Non-communicable Diseases Prevention Policies in Nigeria

30 countries to develop NCD policies by 2013, was the major event that accelerated actions led by the health sector. This finding is supported by quotes from government officials and underscores the fact that NCD policy development predates the UN high-level summit. The journey started like 11 and/or 12 years ago.... It has been a long struggle to start it, but as I have said, the political will to drive the system [is low], because there is need for a strong political will to drive it. It was a journey that has never ended. [Official of the FMOH, code 044] Why is it necessary? Why [do] we suddenly think it is necessary? Like I said, we have made [an] effort in the past; it is not like it is just now we are waking up. But you also have to understand that NCDs [were] not really a very prioritized area in health. I remember when I came in newly, 2011, the UN General Assembly for that year was basically on NCDs, and I remember because we had to develop Nigeria[ s] position on NCDs, and the president had to present that document, and then in that process, of course, it dawns on him [Minister of Health] that he had actually not, we had not done much on NCDs. [Official of the FMOH, code 001] Other factors included the increasing morbidity and mortality burden of NCDs, the need to present implementation status updates at global meetings, and the increasing political will of FMOH leadership. After the 2011 UN high-level meeting, the political priority for NCDs increased (Chinenye, Oputa and Oko-Jaja 2014), resulting in strong, high-level political support for tackling Nigeria s NCD crisis. The FMOH constituted a committee in 2012 comprising health sector professionals to develop the draft National Policy and Strategic Plan of Action on NCDs, which addresses the four major NCDs and the four risk factors. This was approved by the National Council of Health in 2013, but subsequently revised by a multi-sectoral committee in Policy content and best buys addressed Tobacco The 2013 Nigerian Policy and Strategic Plan of Action on NCDs, and its strategic plan, the 2015 National Strategic Plan of Action on Prevention and Control of NCDs, provide the legal framework to protect generations of Nigerians from the devastating health, social, economic and environmental consequences of tobacco use and exposure to tobacco smoke. In respect to content, specific policy elements include: establishing the tobacco control committee and tobacco control unit; tobacco control funding; prohibition of smoking in public places; prohibition on tobacco advertising, promotion and sponsorship; prohibition of tobacco product sales to minors; regulation of tobacco products contents and emissions disclosure; tobacco products packaging and labeling; enforcements and roles of responsible organization; education, communication and public awareness; and miscellaneous efforts such as price and tax measures. This policy addresses all the best buy interventions using the provisions of WHO FCTC through the MPOWER strategy. Specific proposed interventions include: (1) protection from tobacco smoke in public and work places; (2) warnings about the dangers of tobacco; (3) enforcing bans on advertising, promotion and sponsorship; and (4) raising tobacco tax and prices. All best buy interventions for tobacco control using WHO FCTC provisions are reflected in the two documents (see Table 5). Other interventions proposed include: raising awareness about the dangers associated with tobacco use; offering help to quit tobacco use; reducing access to tobacco products, particularly among youth; enhancing capacity for detection and control (including smoking cessation) of tobacco use at all levels of health care; enhancing working relationships with anti-tobacco 16 Analysis of Non-communicable Diseases Prevention Policies in Nigeria 2017

31 coalition groups; ensuring evidence-based monitoring of tobacco use and research; monitoring tobacco use and national tobacco prevention policy; and addressing the economy of tobacco raw materials production. Alcohol Actions proposed to prevent the harmful use of alcohol in the Nigerian National Policy and Strategic Plan of Action on NCDs include the following: (1) prevent underage alcohol consumption; (2) discourage use of alcohol by women of reproductive age; (3) prevent driving or operating machinery under the influence; (4) discourage binge drinking including consumption of toxic local brews; (5) identify and manage alcohol use disorders; and (6) prevent consumption of illegally brewed and distributed alcoholic beverages. These proposed actions align with policies such as community action; health services response; drink-driving policies and countermeasures; availability of alcohol; and reducing the public health impact of illicit alcohol and informally produced alcohol as outlined in the WHO (2010) Global Strategy to Reduce the Harmful Use of Alcohol (World Health Organization 2010b). The only best buy intervention for alcohol outlined in the document is restricted access to retailed alcohol, specifically the prevention of underage alcohol consumption (see Table 5). Nutrition Specific interventions proposed in the national policy are to: provide information; establish dietary guidelines to reduce dietary salt level; eliminate industrially produced trans-fatty acids; decrease saturated fats; promote iodization of salts and limit free sugar; increase consumption of fruits and vegetables as well as legumes, whole grains and nuts; promote breastfeeding and ensure optimal feeding for infants and young children, including in schools; promote responsible marketing of foods and non-alcoholic beverages to children; and ensure provision of accurate and balanced information for consumers. Although all best buy interventions were addressed (details in Table 5), there were no acts to regulate the activities of the food industry with regards to salt and trans fat content of manufactured foods. Most of these proposed actions are largely educational interventions. Insufficient physical activity Specific activities proposed to address insufficient physical activity include: develop and implement national guidelines on physical activity for health; implement school-based programs in line with WHO s health-promoting school initiative; ensure that physical environments support safe and active commuting; create space for recreational activity by ensuring the environments for physical activity are accessible to and safe for all; introduce transport policies that promote active and safe methods of travelling; provide and improve sports, recreational and leisure facilities in educational institutions, workplaces and communities; and increase the number of safe spaces available for active play. Unfortunately, none of these addressed the best buy intervention for physical activity (see Table 5). Analysis of Non-communicable Diseases Prevention Policies in Nigeria

32 Table 5: Risk factors and best buy interventions addressed in the NCD Action Plan Risk Factor/ Disease Tobacco use Policy interventions Tax increases Smoke-free indoor workplaces and public places Bans on tobacco advertising, promotion and sponsorship Health information and warnings Harmful alcohol use Restricted access to retailed alcohol Unhealthy diet Reduced salt intake in food Replacement of trans fat with polyunsaturated fat Public awareness through mass media on diet Physical inactivity None Implementation Plan The National Policy and Strategic Plan of Action on NCDs has a comprehensive implementation plan for tobacco control but not for alcohol. Specific interventions to address the harmful use of alcohol in this regard are mainstreamed into different sections of the policy document, specifically in the section for the reduction of road traffic injuries in Nigeria and the reduction of risk factors for heart diseases. Proposals include health promotion-focused activities regarding increased awareness of drunk driving and road safety, as well as a reduction in point-of-sale availability. According to FMOH, the next steps the FMOH NCD unit to develop a proposal on funding for a stakeholder meeting about comprehensive alcohol policy based on relevant global alcohol control policy. If funded, the policy document developed will be presented to the FMOH for approval, as well as the National Council of Health, which comprises the Commissioner for Health from the 36 Nigerian states and FCT. If approved, the minister will sign on behalf of the government, and consequently disseminate to relevant implementing bodies and stakeholders. Funding of the policy actions is expected to be sourced from governments or private institutions and development partners. For unhealthy diet and insufficient physical activity, actions proposed in the plan include implementation of public awareness programs to promote healthy lifestyles as well as implement policies, plans, standards and guidelines that promote physical activity and the production and consumption of healthy diets. With regards to the monitoring and evaluation (M&E) of outlined activities, Sub section 5.7 of the 2013 National Policy and Strategic Plan of Action on NCDs states that: M&E of the implementation of this policy shall be carried out at various levels as appropriate. The key activity that shall be carried out is M&E at the national levels (which shall be the responsibility of the FMOH). In this respect, all NCD programs at the state and LGA levels shall be periodically monitored and re-assessed to ensure compliance with national policy and guidelines on NCDs, and the FMOH shall regularly monitor NCDs and risk factors nationwide to evaluate the impact of interventions using standard M&E tools. Other mechanisms for the M&E of the impact of the specific interventions on tobacco use are through the population level surveys specifically, the Global Adult Tobacco Survey (GATS) and the Nigeria Demographic and Health Surveys (FMOH 2013) Policy Process FMOH and WHO played strategic roles in the development of the 2013 Nigerian Policy and Strategic Plan of Action on NCDs, and subsequently, the 2015 National Strategic Plan of Action 18 Analysis of Non-communicable Diseases Prevention Policies in Nigeria 2017

33 on Prevention and Control of NCDs, via FMOH coordinating policy development and WHO providing technical assistance and funding. Quotes from respondents support this point: WHO declared that they are there to provide technical support [for the development of the policy documents] and knowledge about diseases [Code 042, Official of FMOH] FMOH was involved as the coordinating unit. All the draft documents go back to the ministry. The ministry is also there as the secretariat of the meeting. Usually the secretary of the meeting is a staff of the ministry who collates all the document and also processes activities related to conducting the meeting, cooking, making arrangement, providing stationeries, and others. [Code 022 Academic and Medical Sector The policy development process for the 2013 Nigerian Policy and Strategic Plan of Action on NCDs commenced with a meeting in which stakeholders, largely experts identified by the FMOH, were invited to develop the policy. They subsequently formed committees to work on sections relevant to their specialty areas: The very first meeting was like an ice-breaking meeting, and it was in that meeting that committees were formed to work on different aspect of the policy. The strategy is to work in committees. To even form the committee, we had the initial discussion, agreement and disagreement on how things should be done and what constitute[s] misuse, what constitute[s] independent, what do you prescribe for people, is it complete abstinence or reduction in consumption all were debated initially before the committees were formed. [Code 022 Academic and Medical Sector] In addition, a procedure adopted to fast-track the process was to use existing NCD prevention policies from other countries, as stated in this quote: So basically, for meetings, we have for policies: we have several meetings, sometimes three meetings, most of the time two meetings. The first meeting, we develop the first draft, we have working documents from other countries to develop the first draft, then the second meetings we enrich that draft and maybe finalize in the third meeting. [Code 022 Official FMOH] Electronic meetings complemented the face-to-face meetings. A respondent said the policydevelopment process was inadequate and not thorough due to the limited time for deliberations, which was linked to poor funding as well as the need to deliver set targets within the limited timeframe, as stated below: We had two full meetings, not up to three. We complemented it with electronic meetings. We formed up subgroups that worked in certain areas. The groups worked on their own and then came to the last meeting to deliberate on the outcome of their meeting. I think to do a thorough job more meetings should have been held. The time[s] allotted for the meetings were short, were pretty short, they were of course, not because the ministry was not willing to spread it for a longer period, but they were bound by the amount of fund available for the meeting. [Code 022 Academic and Medical Sector] Major factors that negatively affected the quality of the 2013 Nigerian Policy and Strategic Plan of Action on NCDs include: ignorance about MSA as a principle for document development and limited time to work on the document, which downsizes the intensive consultative process due to lack of donor funding. Unsurprisingly, the faulty processes affects the quality of the document, and in 2015, the WHO requested a review of the document as well as the formulation processes as expressed below: I have told you about WHO [who requested for a multi-sectoral team,]and I also told you that the FMOH on their own realized it should not be only experts that should be involved in doing that [developing the NCD policy]. {Official of the FMOH, code 042] Analysis of Non-communicable Diseases Prevention Policies in Nigeria

34 Before, the thinking [for the development of the NCD policy] was that we needed expert[s], but for the thing of the past we may say it was ignorance, but now the thinking has been expanded, so there is need to get many people from different sectors that have a say in NCD prevention and control. [Official of the FMOH, code 042] Subsequently, in 2015 WHO supported a multi-stakeholder meeting in which the policy document was reviewed, with the recommendation that two separate documents be produced: specifically, the 2013 Nigerian Policy and Strategic Plan of Action on NCDs and the 2015 National Strategic Plan of Action on Prevention and Control of NCDs. Throughout this process, WHO provided technical assistance and relevant policies developed by other countries as a guide. Let me tell you an interesting thing about the policy and strategic plan: they were together, the policy and strategic plan for NCD, were together in the document, but WHO now said this document is voluminous, there is need to separate policy from strategic plan. And so WHO now supported a stakeholder meeting, a multi-sectoral meeting, where the strategic plan was reviewed and WHO said that is not the current thinking about strategic plan, that the plan should be as broad and feasible using their chart. [We] adopted WHO target[s] and other things by looking at [policies] in other countries, especially Kenya, and came up with a draft of new NCD strategic plan, which is yet to be completed. [Official of the FMOH, code 042] Another major barrier hindering the policy formulation process is the lack of nationally representative data on the prevalence of NCDs and their associated risk factors, as expressed below: One of the major constraints that we had in formulating the policy was the issue of data. All the data we have [is] obsolete. So, we don t have recent data to showcase what NCDs are to present the burden of NCD at the global and local community. We don t have the recent data. So, these are some of the main concerns that we have. Because if you are putting [together] a policy document, you need to back it up with some recent findings [of] what is really happening. So, we don t know whether to rely on individual studies We need national data that is nationally represented. (Official of the FMOH, code 044) An FMOH official also commented that the two documents still need further review before they can be published and disseminated to states for implementation. The WHO commitment to the review process was also reflected. WHO had committed to helping us to do the cross checks and even for the policy too. I am of the opinion that the policy needs to be reviewed as well, that is my thinking. [Official of the FMOH, code 042] In view of these gaps, the policy was not published in hard copy and disseminated nationwide although it has appeared on the internet. A review of the online version indicates the unacceptable editorial quality of the NCD prevention policies. These views are reflected in a quote from an interviewee at the FMOH: Well, from government perspective, you asked if we have a policy because when we say we have a policy, it means the policy has been developed, finalized, approved, published and operationalization has started. But at this stage, as we are talking, policies have not been finalized. So we find it difficult to say we have a policy. But in terms of development, it is being developed. As per finalization to put it to use, we haven t, because if the policy document has been finalized, I am pretty sure even Professor Oladepo will have a copy of that document. So we are right to say we have a draft of the document. [Official of the FMOH, code 001] We still are having issues with funding for NCDs but then the political will is still low, I don t think it is strong enough even after the 2011 Summit on NCDs. [Official of the FMOH, code 001] 20 Analysis of Non-communicable Diseases Prevention Policies in Nigeria 2017

35 The findings underscore the fact that there is a limit to what the global initiatives can achieve when there is political will to drive the process within countries and are no significant changes. Efforts to guide countries in the development of its NCD prevention policies should transcend mere participation at meetings, include stronger regulatory and monitoring actions by global health organizations, coupled with complementary initiatives aimed at building broad-based interest in-country by leveraging strong civil society organizations and academia to drive the process Multi-sectoral involvement MSA used for the NCD action plan outlined in the 2013 National Policy and Strategic Plan of Action on NCDs was initially not extensive. A review of participants reveals that 45 people were involved or provided technical assistance. The breakdown by professional groups/organizations represented shows 31 from the health sector (16 FMOH staff, 15 consultant specialists from tertiary hospitals); five from professional associations/ngos; one from the Federal Road Safety Commission; three WHO representatives; a pharmacist from the Nigerian Academy of Science; a former staff from NCD division; and interns. The finding clearly shows that input was not sought from key sectors relevant to various aspects of NCD prevention. Sectors related to insufficient physical activity information, sports, education, urban regional planning were not involved. Likewise, the food industry, nutrition society of Nigeria, agriculture, information, education and women affairs were not involved in policy development actions for healthy diets. Sectors relevant to alcohol and tobacco use, such as finance, justice, law enforcement agencies, environment and information, were also not involved in policy formulation. However, with WHO recommendation, the committee was reconstituted with a broad representation, so the number of ministries/organizations who developed/reviewed the policy document increased from 45 to 80 [details in Table 6]. Some of the relevant sectors involved were education, information, National Primary Health Care Development Agency, National Health Insurance Scheme, finance, agriculture, Internal Affairs, Standard Organization of Nigeria, Export Promotion Council, Nigeria Customs Service and the Federal Road Safety Commission. Relevant sectors that were not involved in the reconstituted committee but who played a role in policy implementation include: Sports; Environment; Women Affairs; Food Industry and Manufacturers, Urban and Regional Planning; Transportation; and corporate organizations. Although a mitigation strategy was eventually deployed to address the lack of MSA during policy formulation, it is obvious that the policy formulation process was already compromised and this might have a potentially negative implication on the extent of adoption and implementation of the recommended policy actions by the concerned sectors. Analysis of Non-communicable Diseases Prevention Policies in Nigeria

36 Table 6: Stakeholders roles in the development of the NCDs Policy and Plan of Action Stakeholders Details Roles FMOH NCD Division and Public Health Coordinated the meeting; led the policy development process Consultant Specialists/ academia from tertiary hospitals/universities World Health Organization Professional groups and NGOs Religious groups Government institutions Civil society organization Law enforcement Media Conglomerates Regulatory agencies Nigerian Cardiac Society; Nigerian Association of Nephrology; Diabetes Association of Nigeria; Nigeria Cancer Society; Nigerian Heart Foundation; Nigerian Hypertension Society; Sickle Cell Disease Network of Nigeria; National Council for Women Society Christian Association of Nigeria; Supreme Council of Islamic Affairs States ministries of Health, Federal and States Ministry of Education, Federal and States Ministry of Information, National Primary Health Care (PHC) Development Agency, National Health Insurance Scheme, health management organizations, Regional Centre for Oral Health Research and Training Initiatives for Africa, PHC directors in all local government areas, regulatory and professional bodies of PHC and allied health workers, schools of health technology, Federal Ministry of Finance, Federal Ministry of Agriculture, Federal Ministry of Internal Affairs, Standard Organization of Nigeria, Export Promotion Council, and Nigeria Academy of Science Anti-tobacco Coalition Group Nigerian customs services, Federal Road Safety Commission Nigerian Television Authority, dailies, newspapers, National Orientation Agency, Broadcasting Organization of Nigeria Involved in manufacturing of oral health products Medical and Dental Council of Nigeria, Dental Therapists Registration Board Provided technical input during policy development of interventions/actions based on specialties Provided technical input and financial support for policy development of the Provided technical input on policy document development Provided faith-based perspective on implementation of proposed policy actions Provided technical input on development of the policy interventions/actions based on the mandate of their ministries/sectors Provided technical input on development of the policy interventions/actions based on the mandate of their ministries/sectors Provided technical input on development of the policy interventions/actions based on the mandate of their ministries/sectors Provided technical input on development of the policy interventions/actions Provided technical input on development of the policy interventions/actions Legislature National Assembly Not specified 22 Analysis of Non-communicable Diseases Prevention Policies in Nigeria 2017

37 Facilitators to MSA A key facilitator for MSA was the provision of technical and financial support by WHO to the FMOH, which resulted in the constitution of a multi-stakeholder committee to review and revise the initial policy draft. This mitigation effort facilitated MSA and highlights the roles and importance of international agencies in facilitating and supporting MSA Barriers to MSA Poor funding was a barrier to MSA use for the development of the 2012 National Policy and Strategic Plan of Action on NCDs, especially for consultative meeting conduct and speculation that the allocated money might not be used for policy documents development, as expressed below: There are two challenges we envisage: the first one is finance, because bringing people together, one should be ready to bear the cost and then make them comfortable and then provide materials like leaflets, pamphlets and then the other issue is political. So political in the sense that it involves money. It is one thing for the government to devote money, it is another thing for people who are in charge to use that money for the purpose, because when they give money to the people, they think it s their own national cake. [Respondent from Academic and Medical Sector, code 025]. Another barrier includes ignorance or poor understanding of MSA principles and how it should be operationalized, as expressed in the quotes below: Before, the thinking was that we needed experts, but that is a thing of the past. We may say it was ignorance, but now the thinking has been expanded, so there is need to get many people from different sectors that have a say in NCD prevention and control. [Official of the FMOH, code 042] Other barriers include limited timing and overdependence on external donor organizations to fund the policy formulation process. What I will say was a drawback for the process is the fact that the meetings were limited. We were pushed and we were completely dependent on funding agenc[ies]. We had two full meetings, not up to three; we complemented it with electronic meetings, we formed up subgroups that worked in certain areas. The groups worked on their own and then came to the last meeting to deliberate on the outcome of their meeting. I think to do a thorough job, more meetings should have been held. [Respondent from the Academic Sector, code 022] Implementation status The policies were published online in a draft form, but not disseminated to states for adoption and ratification of proposed actions. Implementation is yet to commence Tobacco control policy Policy context and history The development of tobacco control policies and legislation in Nigeria had an eventful pathway. The first attempt by the Nigerian government appeared in a 1951 revenue allocation document on licensing and controlling tobacco importation (Section 6 of the Nigeria Order in Council of 1951) (Nwhator 2011). In 1990, the military government formulated the Tobacco Smoking (Control) Decree 20, 1990, which was converted to an act when Nigeria moved to democratic Analysis of Non-communicable Diseases Prevention Policies in Nigeria

38 rule and was titled Tobacco (Control) Act 1990 CAP.T16 (Federal Republic of Nigeria 1990). The conversion from military to democratic rule influenced a name change in the document, although the content remained the same and guided tobacco control for more than 20 years. This change was necessary because only military rulers used decrees as a tool for governance. The act banned smoking in specified public places and required warning messages on all tobacco advertisement and sponsorship. This policy was weak and poorly implemented, as evidenced by findings in a 2008 WHO report, which revealed a low level of tobacco control implementation (World Health Organization 2008b; Nwhator 2011), and a further study by Winkler et al., 2015, which analyzed MPOWER measures from WHO reports in 2008 and 2010, combined with prevalence data from 2009 and 2011 (Winkler et al. 2015). In 2009, a move by the tobacco control community resulted in the development of a comprehensive, FCTC-compliant tobacco control bill that suggesting a positive local content. To understand the legislative process of bills such as the National Tobacco Control Bill 2009 requires an understanding of Nigeria s governance system. Nigeria has a presidential system of government, and a bill can be initiated by anybody, but only a member of the House of Representatives or a Senate can introduce it on the floor of the National Assembly. Bills are grouped into three categories: Executive, Member, and Private Bills. Bills from the Executive branch of government can at times be discussed concurrently in both the Senate and the House. Member and Private Bills are always first discussed in its chamber of origin before it is sent to the other for passage (Federal Republic of Nigeria, n.d.). In respect of the National Tobacco Control Bill 2009, the legislation is entitled A Bill for an Act to Repeal the Tobacco (Control) Act 1990 Cap T16 Laws of the Federation and to Enact the National Tobacco Control Bill 2009 to provide for the Regulation or Control of Production, Manufacture, Sale, Advertising, Promotion and Sponsorship of Tobacco or Tobacco Products in Nigerian and for other Related Matters. Simply known as the National Tobacco Control Bill 2009, this bill was a civil society-driven process: it was sponsored by a senator from southwest Nigeria and passed in 2011 by the National Assembly after two years of consideration. However, in 2013, the presidency failed to sign the bill (Drope 2011; Agaku et al. 2012; Premium Newspaper 2013). After this failure, another version was facilitated by FMOH and passed as an Executive Bill to the Federal Executive Council and Senate for approval. It was approved after pressure from the tobacco control community and formidable resistance from the tobacco industry. On the 27 May 2015, Nigeria s outgoing president, Goodluck Jonathan, eventually signed the National Tobacco Control Bill 2009 into law, which became known as the National Tobacco Control Act Pressure from civil society and the president leaving office were critical factors that aided its passage. Indeed, it was obvious that the outgoing president decided to sign the bill into act before his exit to not only appease the tobacco pressure group and other stakeholders but also avoid tobacco industry backlash. The National Tobacco Control Act 2015 is a comprehensive, FCTC-complaint legal instrument that addresses all tobacco best buy interventions as well as other measures relating to reducing tobacco demand and supply as well as related matters (Federal Republic of Nigeria 2015a). Specific policy elements addressed include; establishing a tobacco control committee and tobacco control unit; tobacco control funding; prohibition of smoking in public places; prohibition on tobacco advertising, promotion and sponsorship; prohibition of tobacco product sales to minors; regulation of tobacco products contents and emissions disclosure; tobacco products packaging and labeling; enforcements and roles of responsible organization; education, communication and public awareness; and other initiatives such as including price and tax measures (Federal Republic of Nigeria 2015a). 24 Aligned with the National Tobacco Control Act 2015 is the Nigerian National Policy and Strategic Plan of Action on NCDs, developed by FMOH in 2013 and reviewed in This policy addresses all the best buy interventions using the provisions of the WHO FCTC through the use of the MPOWER strategy. The MPOWER strategy (Monitor tobacco use and prevention policies, Protect people from tobacco smoke, Offer help to quit tobacco use, Warn about the dangers of tobacco, Enforce bans on tobacco advertising, promotion and sponsorship, Raise taxes on Analysis of Non-communicable Diseases Prevention Policies in Nigeria 2017

39 tobacco and Reduce the size of cigarette) is a policy package developed by the WHO in 2007 to assist countries implement effective interventions to reduce the demand for tobacco (World Health Organization 2008b). Another policy document, 2014 Standard for Tobacco and Tobacco Products Specifications for Cigarette, was developed by the Standards Organization of Nigeria, which is the government agency that ensures products imported or manufactured in Nigeria comply with government policies on standards based on conformity assessment. This agency not only provides FCTCcompliant specifications on how the packaging for cigarettes carton, roll and individual packet should be marked with health warnings on the dangers of tobacco use but also prohibits flavouring substances that could appeal to children (Standard Organization of Nigeria 2014). The development of this document predates the 2015 Tobacco Act, but a critical review reveals a high level of coherence in both documents on tobacco product packaging and labeling specifications. The only challenge was tobacco industry involvement in the development of the 2014 Standard for Tobacco and Tobacco Products Specifications for Cigarettes, contrary to FCTC recommendations. According to the Standard Organization of Nigeria, the tobacco industry must be involved to guide their manufacturing activities, but their involvement portends a conflict of interest and undermines the development of stronger regulations for the manufacturing and packaging of tobacco products Policy content and best buys addressed Several tobacco policies have been released since the 1990s. The objectives, rationales and best buy elements for each policy or legal instrument differs. A descriptive summary is provided for each in Table 7. The Tobacco (Control) Act 1990 This policy objective is control of tobacco use in certain places and tobacco advertising in Nigeria. The Tobacco (Control) Act 1990 was repealed upon ratification of the National Tobacco Control Act The act addresses best buys such as the control of tobacco smoking in public places, restriction on tobacco smoking advertisement, tobacco warning labels and information on packages. However, neither taxation and price measures nor other tobacco supply and demand measures are addressed. Penalties for violations are generally weak and no longer relevant 26 years after its ratification (Federal Republic of Nigeria 1990). A summary description is outlined in Table 7. The National Tobacco Control Act 2015 The National Tobacco Control Act 2015 is the core legal instrument that guides prevention and control of tobacco use in Nigeria. This document succinctly and adequately addresses all the best buy interventions. Part III, sub-section 9 addresses the prohibition of smoking in public places; part V, sub-section 12 outlines actions to prohibit tobacco advertising, promotion and sponsorship; part VIII specifies actions for warning people about the dangers of tobacco; and part XII, sub-section 43 addresses tobacco taxation and price measures. Other tobacco supply and demand measures proposed include the establishment of the national tobacco control committee and the tobacco control unit; tobacco control fund; regulation of tobacco product sales; regulation of tobacco product content and emissions disclosure; licensing of tobacco dealers; and enforcement, training and public awareness campaigns (Federal Republic of Nigeria 2015b). Although the act contains strong points, gaps still exist. The requirements for the health warning are textual, written only in English, without the use of graphics or pictorials that convey more information to illiterate Nigerians. Furthermore, there are insufficient measures against the corporate social responsibility/activities of the tobacco industries. The act requires FMOH to obtain approval from the National Assembly before implementation, which is another Analysis of Non-communicable Diseases Prevention Policies in Nigeria

40 potential bureaucratic process capable of hindering effective implementation. A summary is outlined in Table 7. The 2014 Standard for Tobacco and Tobacco Products Specifications for Cigarettes The Standard for Tobacco and Tobacco Products Specifications for Cigarettes was developed in 2014 in line with relevant FCTC guidelines and replaces the 2008 edition. The document states the standard s premise is based on wide cigarette consumption Nigeria and the increase of illicit trade on tobacco products, as well as the need to provide the public adequate information on risks associated with tobacco products. The 2014 Standard for Tobacco and Tobacco Products Specifications for Cigarettes is from the non-health sector, specifically, the regulatory body for the production of goods in Nigeria. Section 8 addresses only one best buy intervention, health information and warnings (see Table 7). The document also addresses other requirements for the manufacture and production of tobacco and cigarettes. Table 7: Tobacco policies, the best buys addressed and year of development Policy/year Objective Best buy addressed Source of info (Reference number or interviewee code) National Tobacco Control Act 2015 Provide legal framework to protect generations of Nigerians from health, social, economic and environmental consequences of tobacco use and exposure to tobacco smoke All best buys, specifically protecting people from tobacco smoke in public and work places; warning people about the dangers of tobacco; enforcing bans on advertising, promotion and sponsorship; and raising tobacco tax and prices Code 002; 027 and National Tobacco Control Act 2015 Tobacco Control Act 1990 CAP.T16. Control tobacco use in certain places and tobacco product advertising Warning people about the dangers of tobacco; and enforcing bans on advertising, promotion and sponsorship Tobacco Control Act 1990 CAP.T16 Standard for Tobacco and Tobacco Products Specifications for Cigarettes Create a level playing field for product manufacturers, importers, and marketers; safeguard consumers health Health information and warnings Standard Organization of Nigeria, Policy process Drope et al., 2012 provided a succinct analysis of the policy process for tobacco legislation in Nigeria. Previous attempts dating from as early as the 1990s were made by the government to regulate tobacco manufacturers. This resulted in the passage of Tobacco Smoking (Control) Decree 20, Considering the political milieu of a military dictatorship, the process was not participatory and inclusive. In the early 2000s, when Nigeria transitioned to a democracy, the decree was converted to Tobacco (Control) Act 1990 CAP.T16. This act regulated the activities of the tobacco industry for more than 20 years. A National Smoking Cessation Committee was 26 Analysis of Non-communicable Diseases Prevention Policies in Nigeria 2017

41 inaugurated in 1999 to develop a short-term plan of action, and in 2002, there was a total ban on tobacco advertisement by the Advertising Practitioners Promotion Control of Nigeria (APCON). Despite these actions, there were mixed messages about tobacco control. For instance, in 2001, the Nigerian government signed a memorandum of understanding with British American Tobacco Nigeria (BATN) to build potential for regional export, significantly increase the quantity and quality of locally grown tobacco, and establish an independent charitable foundation to support socioeconomic development (British American Tobacco Company 2012). In 2008, BATN established a state-of-the-art manufacturing hub for the entire West African region in Ibadan, Nigeria, reflecting the Nigerian government s insincerity and inconsistency to tobacco control. Nigeria signed the FCTC and ratified it on 20 October 2005, further driving interest in tobacco legislation. For instance, in 2007, the FCT minister introduced an Abuja smoke-free policy although it was limited to the capital city and not implemented nationwide. FCTC ratification prompted further interest for the development of a national comprehensive tobacco control bill, which was an issue of mutual interest in the tobacco control community. Tobacco control advocates and civil society organizations can be credited as the force that positioned and sustained tobacco control on the national agenda with subsequent buy-in from other supporters in and out of government. The path of the National Tobacco Control Bill 2009 through the National Senate was tortuous. The National Senate version of the legislation was sponsored by Lagos East senator and deputy minority leader Dr Olorunnibe Mamora, M.D., and received its official second reading in February According to tobacco control advocates, BATN actively sought to halt its passage and prevent the bill from advancing to committee stage, but the vigorous efforts of civil society organizations countered those actions. The bill was considered in a formal public hearing by the Senate Health Committee in July The bill received a major boost from the Professor Babatunde Osotimehin, Minister of Health, and Senator Jibrin Aminu, a former minister, ambassador, two-time senator and chairman of the Senate Committee on Foreign Affairs, who publicly spoke out in support of the proposed legislation (Drope 2011). The bill also received strong support from many domestic and international civil society groups. Three Nigerian NGOs, Environmental Rights Action/Friends of the Earth, Nigeria; the Nigerian Tobacco Control Alliance; and the Coalition Against Tobacco also contributed support. The bill was commended by international agencies and NGOs. Similar to findings in several countries, the bill was met with strong opposition from the BATN, who used tactics such as diplomacy to stall the bill. Many senators did not clearly define their stance on the tobacco bill. For instance, National Senate President David Mark, an influential leader in the legislature, said: We are torn between economy and the health of Nigerians in passing this bill, but we ll not compromise because it s only those who are alive that can talk about economy (Drope 2011). The Senate President however, expressed reservations about the bill. He said: I will remain neutral on this bill because the two key issues are health versus economy (Drope 2011). Despite his remarks, he supported the legislation, which was eventually passed at both House and Senate. The presidency failed to sign the bill in 2013, most likely due to tobacco industry pressure. With the presidency failing to give its assent, the FMOH facilitated the Executive Bill for Tobacco Control, with active support and contributions from tobacco control advocates in and outside government. The process was participatory and consultative, with representation from diverse health and non-health sectors, civil society organizations, professional bodies and international organizations. However, one challenge was determining which sectors should drive the process. The quote expressed by an interviewee supports this finding: Well, let me say that the tobacco policy brought together a lot of stakeholders, major stakeholders, but we went about it at the ministry levels. It created rivalry; many ministries felt they should be in charge of certain aspects of the Tobacco Control Bill, and that created a lot of setbacks. And that also was a major factor in 2009 tobacco bill not being assented to by Mr. President, because of objections by certain ministries. [Tobacco Researcher and Academia, Code 027] Analysis of Non-communicable Diseases Prevention Policies in Nigeria

42 Eventually, this hurdle was surmounted by dialogues and consensus; the FMOH had the mandate to champion its development and passage. The Executive Bill was presented by Senator Chris Ngige on behalf of the health committee after a significant delay and inaction at the Senate. Deputy Senate President Ike Ekweremadu, who presided over the session in which the bill passed, said this was a milestone. He noted that the dangers associated with smoking cannot be over-emphasized. Eventually, the bill was passed at the Senate and the House of Assembly, but obtaining President Jonathan s final assent and approval was a challenge. Several approaches were used to support the passage of the bill, such as professional medical association representatives publishing position papers in newspapers, appealing to the moral conscience of the president and members of the 7th National Assembly to leave a lasting legacy for the administration by signing the tobacco bill. These approaches yielded the expected outcome as the president signed National Tobacco Control Act 2015 into law few days to the expiration of his tenure. On paper, this fulfilled Nigeria s obligation through ratification of the WHO FCTC. After legislation of the tobacco bill, there was a change in government and for more than a year, there was no further action on the tobacco act. However, tobacco advocates continued agitating for implementation of the act, and in July 2016, FMOH inaugurated the National Tobacco Control Committee (NTCC), which comprises representatives of health and non-health sector: justice, environment, agriculture, education, Nigeria Customs Services, National Agency for Food and Drug Administration and Control (NAFDAC), National Drug and Law Enforcement Agency, Standards Organization of Nigeria and civil society organizations. At the inauguration of the NTCC, Isaac Adewole, Minister of Health, affirmed that government will adopt all legal and administrative measures to ensure effective implementation of the National Tobacco Control Act (The Cable 2016). The NTCC is headed by Ukoli Onawefe, a professor from the University of Jos, Nigeria, and its objective is to advise and recommend best practice to the minister on the development and implementation of tobacco control policies, strategies, plans, programs and projects, in accordance with World Health Organization FCTC (The Cable 2016). As the tobacco bill passed legislative hurdles, the Standard Organization of Nigeria updated the 2008 version of the Standard for Tobacco and Tobacco Products Specifications for Cigarettes, which was published as the 2014 Standard for Tobacco and Tobacco Products Specifications for Cigarettes. The document was updated to reflect FCTC-relevant decisions and policy actions. After ratification of the FCTC, the guidelines on tobacco control need to align with those proposed in the FCTC. This was without doubt influenced by the strong MSA for the development of the 2015 Tobacco Control Act, which ensured all relevant sectors were conversant with FCTC requirements and initiated actions for tobacco control in their policies in line with the FCTC Multi-sectoral involvement The policy process that led to the enactment of the National Tobacco Control Act 2015 adopted MSA principles. Relevant stakeholders participated in several organized meetings to develop the bill. Table 8 summarizes the level of involvement of each participating organization. The NCD division of FMOH spearheaded the development of the Executive Bill for tobacco control, and according to respondents from FMOH and academia, a diverse range of actors were involved in formulating and facilitating this enactment. According to data from multiple documents and interviews, several government institutions and CSOs were involved in development of the bill: We coordinated all the meetings and all deliberation where stakeholders gathered and we also streamline for the draft of the policy. The development of the tobacco act was multi-sectoral. In fact, you can count almost all the ministries, departmental, agencies. But let me give you a few: 28 Analysis of Non-communicable Diseases Prevention Policies in Nigeria 2017

43 Health as the coordinating ministry, Justice, the Environment, Agriculture, Trade and Industry and Investment, Education, Consumer Provision Council, Standard Organization of Nigeria, National Drug Law Enforcement Agency (NDLEA). [Official, FMOH, code 044] We involved the regulatory agency like Standard Organization of Nigeria, Federal Ministry of Justice, Federal Ministry of Education, Federal Ministry of Youth and Sports, Federal Ministry of Women Affairs, National Bureau of Statistics, the military, the police, World Health Organization and the NGOs. [Official, FMOH, code 009] Sectors that were involved were Ministry of Education, Ministry of Women Affairs, finance, Standard Organization of Nigeria. Custom and the academia [were] involved later CSOs were involved all the way, also the Ministry of Justice. [Respondent, Academic and Medical Sector, code 027] Table 8: Involvement of organizations in the enactment of the 2015 Tobacco Control Act Organization FMOH Academia and professional groups Members, House of Representative and the House Committee on Health Line ministries (Finance, Education, Trade, Standard Organization of Nigeria, Justice, Youth and Sports, information, Women Affairs, National Bureau of Statistics, the military, the police, WHO, NGOs) Level and type of involvement The level of involvement was very high. FMOH led the process for the development of the Executive Bill for Tobacco Control and presented it to appropriate government bodies/institutions for approval. It also coordinated all meetings and drove the tobacco legislation agenda. The level of involvement of the academic sector was very high. They provided evidence from published articles in other countries to support the drafting of the tobacco bill and participated in several consultative meetings to provide technical expertise such as developing presentations for public hearings. The level of involvement was high. The House Committee on Health, headed by Senator Chris Ngige, sponsored the bill and supported its passage in parliament. They also participated in the public hearing of the tobacco bill. Involvement was high: they participated in several meetings for drafting and revising the bill and supported its eventual legislation. They provided technical expertise and contributed to development, especially by specifying the roles and actions they would implement based on the mandate of their ministries/departments/agencies (MDAs). Some of these MDAs are also members of the newly inaugurated National Tobacco Control Committee, which is expected to guide the implementation of the 2015 Tobacco Act. Strategies used to bring sectors together were: invitations to meetings, formation of committees and TWGs. The engagement process commenced with letters written to the relevant MDAs informing them about the need to develop a tobacco bill and the critical roles of their ministries. A committee was formed with representatives from these MDAs, who were involved at the very early stage in the development of the tobacco bill. They were informed at the primitive stage because they are working either directly or indirectly on tobacco. Of course, like Standard Organization of Nigeria, [emphasis is] on standards and quality control; then agriculture about the tobacco farmers. The tobacco farmers need to be supported because tobacco does not grow with other crops. It kills other crops; it does not encourage mix-cropping. The agricultural sector is beginning to win tobacco farmers to fit other alternatives necessary. Another stakeholder I fail to mention is Ministry of Finance, Federal Inland Analysis of Non-communicable Diseases Prevention Policies in Nigeria

44 Revenue, and very important, Nigeria Custom Service. They were all brought on board. [Official FMOH, code 044] Meetings were held by this committee to draft the bill and the consultative process continued even after legislation. In addition, the diverse sector has actions to implement through their ministry budget or annual plan, as stated in the quote below: We held uncountable meetings. And the meetings [are] still ongoing because we need to operationalize the act. The act cannot be operationalized by the Ministry of Health alone; it cuts across all the players. The section that agriculture will enforce, they should know that they will enforce a particular section. The provision that Custom has to enforce, Custom should know they are really collecting the adequate revenue for government. So, everyone has a stake. [Official FMOH, code 044] Tobacco industry and users were also involved in this process, as deduced from the quote of a member of the legislature, who participated in the public hearing of the bill: Yes, the chronic smokers came [for the public hearing of the bill], I remember someone was given an opportunity. Whether they came as an association, I am not sure. [Member, House of Representative code 011] Representative of the different sectors who developed the bill also indicated a great depth of involvement in the process as stated in the quotes below: Well, all the way, [I] am deeply involved in terms of providing technical expertise, evidence from [the] academi[c] side, evidence of the best practices, and actually also monitoring the industry to see their antics and be able to warn and say we must not go this way. [Respondent, Academic and Medical Sector, code 027] I think the evidence [has] been used all the way and we have a robust bill, which we hope will not be water[ed] down, we have had a public hearing for the house of reps. I was involved in putting together all the document for the public presentation and (soon) we are expecting it to reach the outcome. [Respondent, Academic and Medical Sector, code 027] Involvement was also reflected by the way other sectors provided support for the process, as expressed in the quote below: Many groups were willing to fund themselves and support themselves during the development [of the tobacco bill] without collecting a dime. [FMOH Official, code 044] Table 9 presents the scoring for MSA in tobacco policy formulation. 30 Analysis of Non-communicable Diseases Prevention Policies in Nigeria 2017

45 Table 9: Scoring for MSA in tobacco policy formulation Policy Sectors involved Relevant sectors not involved MSA Rating 1990 National Tobacco Decree and Act No information No information No information National Tobacco Control Act 2015 FMOH, Ministry of Justice, Ministry of Education, Ministry of Agriculture Standard Organization of Nigeria, National Drug Law Enforcement Agency, Consumer Protection Council Research and Academic institutions and professional associations WHO, NGOs/CSOs, religious associations None, all relevant sectors wereinvolved High Standard for Tobacco and Tobacco Products Specifications for Cigarettes 2014 Professional Group Institute of Chartered Chemists of Nigeria Academia National Agency for Food and Drug Administration and Control, Nigerian Agricultural Quarantine Services, Standard Organization of Nigeria BATN, International Tobacco Company International Marketing Promotion Services NCD Division, Federal Ministry of Health, other ministries such as Justice, Information, Law enforcement Moderate Facilitators to MSA The understanding of the tobacco committee is that the FMOH cannot solely implement actions proposed for tobacco control without the involvement of all relevant line ministryies/organizations. This is a key facilitating factor and is supported from the quotes below: The act cannot be operationalized by the Ministry of Health alone; it cuts across all the players... [FMOH Official, code 044] Well, involving all these sectors would ensure that its [strategies] are implemented and would also ensure that there is a national framework into which the activities can fit. [Respondent from Academic and Medical Sector, code 027]. Another factor that enhanced MSA was the perception that the all relevant sector involvement will produce a quality tobacco legislation that addresses their interests: You have a better document, a tested document that will appeal to everyone. I mean, if you bring in a tobacco bill without informing the producers, there are certain things you don t know that they will tell you; if you don t bring in the smokers, there are certain things they will tell you, so you have a better law in place when all the sectors are involved. [Member, House of Representative code 011] Another facilitator was the funding for the multiple consultative meetings required for the drafting and development of the bill. WHO provided some funding to support the meetings. In addition, some sectors funded their representatives participation at these meetings, thereby reducing the financial burden on the FMOH. We had support from WHO and also the Campaign for Tobacco-Free Kids, who funded the meetings. [FMOH Official, code 044] Analysis of Non-communicable Diseases Prevention Policies in Nigeria

46 Yes, we had challenges of funding, but we try our best to circumvent such. And many groups were willing to fund themselves and support themselves without collecting a dime. [FMOH Official, code 044] Sharing ideas from diverse sources with enhanced output increased the sense of joint ownership by bringing people together, which was identified as a potential facilitating factor for MSA, as illustrated in the quotes below: You have diverse perspectives being brought together and there are things that will be hidden from agency A because agency B is exposed to different view, or different perspective or different area they are able to cover it. So you have a wider reach in terms of policy document and even in terms of implementation. [Official of Government Regulatory Agency, code 014] One of the benefit[s] is ownership, because we are bringing people along. Everybody [a] has sense of belonging in the policy implementation. It is more successful, faster, and people see it as their policy, their program, because there is series of activities, [and] those activities are their activities So there is sustainability. [Official of FMOH, code 004] Barriers to MSA Challenges and barriers to MSA use in formulating the Tobacco Control Act included contentions with regards to the appropriate ministry or government agency on who would take the leadership position and drive the policy formulation process. Let me say that tobacco policy brought together a lot of stakeholders majorly but... at the ministry levels, it created rivalry. In many ministries [they felt they] should be in charge of certain aspect[s] of [the] Tobacco Control Bill and that created a lot of setback. And also, [it] was a major factor in the 2009 tobacco bill not being accepted by [the] president because of objection by certain ministries. One of the challenges was that we should be [in] the driver s seat. [Respondent from Academic and Medical Sector, code 027]. Yes, there were issues of mandate, issue of resources. [Official of the Federal Ministry of Women Affairs, code 036] For instance, using NAFDAC as an example now, the people that told me maybe we should work together with ABC, but how do you work with ABC when your resources come differently? Any activity that we undertake, we have to provide the resources to do that, like lunch money and all that so many things you have to do. So, if you have a multi-organizational or multi-agencies working arrangement, you now have to saddle the logistic arrangement, because you have to agree on who is to do one thing and who is to bring what before you can do it, whereas I am here, once, determined that we want to do something. We take off and we do it. [Official of the Food regulatory agency, code 014] These quotes suggest a lack of clarity about mandates and the mechanism for resourcing the activities were key barriers. Also notable was the conflict of interest with how the different sectors operated in regards to their relationship with the tobacco industry. According to WHO FCTC, countries should not involve the tobacco industry in the development of a bill in order to prevent undue interference in undermining the content of the bill. On the other hand, the Standard Organization of Nigeria, according to its mandate, is expected to work with industries and manufacturers to develop manufacturing guidelines. These expectations are contrary to the requirements of the development of the tobacco bill as proposed by WHO, and were an issue in the MSA process: The Standard Organization of Nigeria believes that the tobacco industries are stake holders and therefore that in anything that is being done about tobacco, the tobacco industry must be present. Whereas the health ministry believes that it is a health issue and the industry have stood 32 Analysis of Non-communicable Diseases Prevention Policies in Nigeria 2017

47 in the way of progress for passing tobacco control bill. the Standard Organization of Nigeria believe[s] also that they should be in charge of regulation and that they are already lost within the act that set up the standard Organization of Nigeria, that would control this area. And there is need for a separate law to do that [separate law for regulation]. [Respondent from Academic and Medical Sector, code 027]. Though there (Nwhator 2011) was funding support from some donor organization, insufficient funding was identified as a barrier to MSA: Yes, we had challenges of funding [for the meetings], but we try our best to circumvent such that is in addition to the support from WHO and Campaign for Tobacco-Free Kids. (FMOH Official, code 044) Status of Implementation Prior to the enactment of the 2015 Tobacco control Act, the Nigerian Government implemented some activities/interventions based on the National Tobacco Control Act Bans on tobacco advertising, promotion, and sponsorship This includes the ban of concerts once sponsored by Benson and Hedges, and tobacco billboards were removed down by 2005 (Walker 2008; Nwhator 2011). The federal government further accused tobacco businesses of targeting young smokers by promoting the sale of individual cigarettes, which hinders the effectiveness of mandatory health warnings printed on packets (TumeAhemba 2008). In 2007, the federal government, in conjunction with several Nigerian state governments, filed a suit against the tobacco industry for tobacco-related diseases and treatments in Nigeria. They also banned the sales and advertisement of cigarettes to those under 18, and in stores a kilometer away from facilities used by children, such as playgrounds, schools, cinemas, and hospitals (TumeAhemba 2008). Tax increases Tobacco taxation was also implemented to an extent. For instance, in 2008, the share of tobaccospecific tax on widely consumed of cigarettes in Nigeria was 28 per cent. This is abysmally low compared with other African countries, such as Ghana or Seychelles, which had a total tax of 55% and 79%, respectively (World Health Organization 2008b). The 2015 WHO report indicated a further decline in the total tax (20.63%) although it is recommended that tobacco excise taxes be set above 70% of the retail price of the product to increase prices and reduce consumption (World Health Organization 2015b). Smoke-free indoor workplaces and public places Although Nigeria s Tobacco Act 1990 prohibited smoking in public places, the extent of enforcement and implementation remained low. For instance, the Nigeria Youth Tobacco Survey (2008) found that a high proportion of young people were exposed to secondhand smoke in public places ranging from 35% in Ibadan to 46.9% in Cross Rivers and 55.8% in Kano (Ekanem 2008). The 2012 GATS also found that the percentage of adults aged 15 and older exposed to tobacco smoke in government buildings, public transportation, restaurants, and bars in the 30 days preceding data collection were 3.5, 6.9, 7.9, and 7.2 respectively (FMOH 2012). Health information and warnings With regards to health information and warning, only 54.7% noticed health warnings on cigarette packages (FMOH 2012); and this could be linked to the fact that the country has not specified Analysis of Non-communicable Diseases Prevention Policies in Nigeria

48 the percentage of principal display area of a cigarette to be covered by a health warning. Most tobacco industries capitalized on this and use barely legible prints. However, in the 2014 Standard for Tobacco and Tobacco Products Specifications for Cigarettes, the mandated percentage of principal display area is 50% (Standard Organization of Nigeria 2014). The 2015 National Tobacco Control Act enacted in May 2015 is FCTC-compliant, but implementation has not commenced despite an inaugurated committee in July 2016 to guide it. Mechanisms to fund implementation are outlined in the policy document. Section III of the act stipulates that a Tobacco Control Fund should be established. The fund should consist of: a. monies as may be made available by the federal government from annual budgetary allocation, approved by the National Assembly; b. monies in form of subventions from any of the governments of the federation to meet the stated objectives of this act; and c. gifts, donations, and testamentary disposition (Federal Republic of Nigeria 2015b). Although the M&E plans were not succinctly stated in the policy documents, there were affirmative statements that indicated they will be addressed in the operationalization of the legal instruments. For instance, Part XI, subsection 40 of the National Tobacco Control Act 2015, states that the Minister of Health shall establish appropriate mechanisms for the M&E of the provisions of this act, and ensure the effectiveness of the inspection and enforcement provisions provided therein. Furthermore, evaluation shall include an assessment of the impact with respect to different population and vulnerable groups, such as women, youth, and low-income populations. These measures have not yet been operationalized Alcohol control policy Alcohol policy context and history Nigeria has no comprehensive policy for alcohol control, and there is no national monitoring system for alcohol consumption, health and social consequences, or policy responses (World Health Organization 2011b; World Health Organization 2014b). There is no comprehensive policy to regulate production, marketing, advertising and availability of alcohol, despite the country s participation and adoption of resolutions at the World Health Assembly of 24 May 2008 and several other meetings that stipulate countries should a draft global strategy to reduce the harmful use of alcohol by 2010 (Dumbili 2014). This finding is corroborated by quotes from the key informants: To be honest with you, do we really have policies on alcohol in this country? We don t, because I can just walk into any bar parlour, any garden, if I want to take a carton of beer, nobody would It s not punishable, you know. You are allowed to drink whatever quantities you want, you understand, nobody restrict[s] you, it s a free thing. So, I don t think the government has a policy on alcohol. [Official of the Federal Inland Revenue Services, code 003] 34 Yes, I know alcohol is a big issue, especially for NCDs. We at the moment don t have a policy on alcohol, but we ve been pushing for that, and it is a welcome idea because we ve gone for international fora on alcohol control so my boss had to go for that meeting. And he came back and of course we don t have a policy, but he came back with some documents that we can adapt in Nigeria, and we have. Actually, as I speak to you now, we have a proposal. We have done a proposal in the past, couple of years ago, but nothing was done about it, so of course we ve done the proposal again to call stakeholders together to develop a comprehensive policy on alcohol control, and wide range of stakeholders will be involved. I don t have the names of all the stakeholders but l know that the alcohol companies will also be invited. [Official of the Ministry of Health, code 001] Analysis of Non-communicable Diseases Prevention Policies in Nigeria 2017

49 From the aforementioned, the respondents mentioned that the FMOH developed a proposal aimed at organizing and mobilizing stakeholders to develop a comprehensive policy for alcohol prevention. Prior to commercialization of alcohol production and consumption in Nigeria, alcoholic beverages were consumed almost at point of production, and alcohol trade existed at a low scale (Obot 2007). The commercialization of alcohol resulted in an urgent need to regulate and control its use, but the government failed to properly regulate alcohol producers (Obot 2007; Dumbili 2014). In addition, the country does not have a legal policy stipulating alcohol unit content on bottles and cans, neither is there stipulation for the inscription of health warning information nor prohibition of alcohol sales to minors or known alcoholics (Dumbili 2013). There are no sobriety check points or random breath testing. The number of standard alcoholic drinks is not displayed on containers (World Health Organization 2014b). However, licensing is required for the production and sale of alcohol, and alcohol content is displayed on containers (WHO, (World Health Organization 2014b). Alcohol marketing is not restricted. In 2010, the leading alcohol transnational companies, and their subsidiaries, were among the 10 largest advertisers in Nigeria (Advertising Age 2012). Most of these aggressive marketing activities target young people through events such as Star Quest, Star Trek and Guilder Ultimate Search, where foreign and local musicians are sponsored to perform and promote their products (Obot,. & Ibanga 2002; Jernigan & Obot 2006). In Nigeria, the International Center for Alcohol Policies (ICAP), an NGO established and sponsored by global alcohol producers, worked with the Beer Sector Group of the Manufacturers Association of Nigeria and the Advertising Practitioners Council of Nigeria to advocate for selfregulation (International Center for Alcohol Policies 2011). ICAP s social responsibilities and activities are strategically aimed at distracting government from developing policies in line with the WHO s 2010 resolution (Dumbili 2014). The country relies on brewers self-regulatory drink responsibly campaign, which is highly ineffective (Dumbili 2013). Self-regulation is ineffective in many countries and creates a milieu in which self-regulatory codes are adopted but not enforced (Babor et al ; Alcohol and Public Policy Group 2010). After Nigeria s oil boom in the early 1970s, RTAs escalated and turned the country into one of the most RTA-prone nations in the world, second only to Ethiopia. In response, in 1988 the Nigerian government established the Federal Road Safety Corps (FRSC) and tasked it with specific duties and functions (The Nations Nigeria 2015). FRSC supported the Federal Road Safety Act (2007) a policy document in the non-health sector that has interventions for alcohol control (Federal Road Safety Commission 2007) to curb the increasingly high prevalence of RTAs and injuries in Nigeria Policy content and best buys addressed The policy objectives of the Federal Road Safety Act (2007) is to prevent and minimize road accidents on highways and outlines two actions relating to alcohol control: persecution or penalty for persons who (i) drive or attempt to drive a motor vehicle on a highway under the influence of drugs or alcohol, (ii) sell or take alcoholic drink or hard drugs within 200 meters radius of a motor park, motor cycle park or bus stop. The actions proposed in this policy document align with recommended actions outlined in the World Health Organization (World Health Organization 2010b) Global Strategy to reduce harmful use of alcohol, specifically drink-driving policies, countermeasures, and alcohol availability. The only best buy intervention for alcohol is restricted access to retailed alcohol. Table 10 provides a summary of the best buys addressed for alcohol control. Analysis of Non-communicable Diseases Prevention Policies in Nigeria

50 Table 10: Alcohol interventions mentioned in other documents Policy Best Buy addressed Year of development Source of Info (reference number or interviewee code) National Policy and Strategic Plan of Action on NCDs Mentions restricted access to retailed alcohol 2012 (reviewed ) Code 001; 002; 031 The Federal Road Safety Act Restricted access to retailed alcohol 2007 Code Policy process The Federal Road Safety Commission Bill of 2007, sponsored by Senator Chris Adighije, became the Federal Road Safety Commission Act of The act was developed to prevent and minimize road accidents on highways, clearing obstructions on highways, educating drivers and other members of the public on the proper highway use and protecting and treating RTA victims. Although the act s original intent was to curb the high prevalence RTAs, it also proposed actions for alcohol control, and if well implemented, it would significantly reduce the harmful use of alcohol Multi-sectoral involvement Given the absence of a comprehensive alcohol control policy in Nigeria, the extent of MSA use in forming the 2007 Federal Road Safety Act appears low. The 2009 FRSC Corporate Road Map lists only seven organizations who had input into its development: the FRSC, Secretary to the Government of the Federation, National Planning Commission, Bureau of Public Enterprises, National Emergency Management Agency, Office of the Economic Adviser to the President, and Budget Office of the Federal Government of Nigeria. This indicates the limited use of MSA and the low level of involvement of relevant sectors. A possible reason for the low MSA can be attributed to the paramilitary nature of the institution that guides its mode of operations. A plan to involve other sectors in the implementation of proposed activities was outlined in the 2009 FRSC Corporate Road Map. Proposed stakeholders include: e Vice President of the Federal Republic of Nigeria, the Chairman of Governors Forum, Secretary General of the Federation, Ministry of Works, Ministry of Health, Ministry of Justice, Ministry of Education, representatives from Nigerian Union of Road Transport Workers, National Automotive Council and Nigerian Union of Journalists. However, there is no information about whether stakeholders were constituted or whether they were functional. Table 11 presents the scoring for MSA in tobacco policy formulation. Table 11: Scoring for MSA in alcohol policy formulation Policy Sectors involved Relevant sectors not involved Federal Road Safety Commission Act (2007) MSA Rating No information No information Low from the review of the policy 36 Analysis of Non-communicable Diseases Prevention Policies in Nigeria 2017

51 Potential facilitators to MSA Factors that have potential to facilitate MSA, as stated by the interviewees, include empowerment through training and funding. Government should empower them [actors/government institution involved in implementing policy actions] with regulations and financial back-up. [Representative of Professional Body, code 018] Implementation plan The Federal Road Safety Commission developed the 2009 Federal Road Safety Commission Corporate Road Map to actualize its vision and strategies (Federal Road Safety Commission 2009). A review of this document indicates actions proposed for road safety but there are no clearly defined activities for alcohol control in line with the 2007 FRSC act. The only alcohol-related activity proposed was the development of research data on drivers blood alcohol concentration Challenges to alcohol policy development and implementation The current status of formulation or implementation of the alcohol policy is very poor. According to respondents, some barriers for the alcohol control policy s formulation and implementation include its relevance as a social substance and associated difficulty in regulating it: Well, alcohol is a social substance and many cultures permit the usage So, it become[s] a little bit difficult if there is no awareness about what to do, and I think it [was] the major factor in the implementation [of the FRSC act], which has been near zero. [Representative of the Academic and Medical Sector, code 027] Other challenges include the government s failure to strengthen systems and structures that enforce policies, poor mobilization of law enforcement agencies, and the lack of a concise policy or act to regulate the activities of the alcohol industry due to lack of resources and poor prioritization of alcohol control activities. Respondents further identified challenges including: funding limitations; lack of equipment such as breath analyzers; poor literacy; lack of policy specification on labeling of alcoholic beverages; and a failure to mobilize appropriate government structures to implement assigned actions on alcohol. Of course [we have] a few act[s] of parliament prohibiting, for example, drunken driving. Outside that, I don t know whether that act also prevent[s] excessive alcohol in public places, you know, but I know that of course we have not even implemented that one in the sense that we don t have kits where we can check the blood levels of alcohol and stuff like that. We don t have them. Then of course the alcoholic breweries in Nigeria that produce alcohol, I don t see a proactive way to try to enforce government policies. Some of [the labeling of alcoholic drinks content] are not laws, for example, having extra information on their label-alcohol is dangerous to your health and all those things.. I have really not seen that, like the tobacco, you know. I am not satisf[ied] really with policies regarding alcohol in Nigeria. It is an area we need to push forward. [Member of the House of Representative, code 011] Well, like in any developing nation, we are clouded with so many issues, so a lot of times system-strengthening has not been effectively done, so it is difficult, you know, meagre resources, illiteracy, the fact that government cannot even put structures to enforce them Even when they exist, the law enforcement agencies are not mobilized in such a manner to have that conscious level, so, I think it is a myriad of problem like in any other developing countries. [House of Representatives, code 11] Analysis of Non-communicable Diseases Prevention Policies in Nigeria

52 In addition, alcohol information and warnings are unclear and ambiguous. That [ drink responsibly policy] has not been effectively implemented because of individual difference[s] on what constitute[s] responsible drinking. For some, two bottles of beer are enough, for others, two is not even near average. And evidently, even with the policy, people still get drunk and misbehave. [Representative of Professional Body, code 018] So even though drink-drive policy exists, its implementation was hampered by these factors. According to the interviews, the 2007 Federal Road Safety Act s interventions were haphazard but yielded some impact. For instance, during the festive season, the FRSC provides data on accident causalities, and this results in increased awareness, interventions, enforcement agency monitoring and use of devices to test for alcohol and prohibit drink driving. However, it has not been a sustained initiative: I think it [implementation of policy actions in the 2007 Federal Road Safety Act] is almost like a sporadic thing, you know. At the end of the year, the Federal Road Safety Commission comes up with the figures of accident[s], comparing them. This results in a reaction from government, and then you have some kind of one-off program being made, and that is all. It has not been very consistent. For example, there would be radio jingles or television advert[s] or even newspaper media, but after some time, it stops. So it has not been very consistent. [Representative from the Academic and Medical Sector, code 019] Sale of alcoholic drinks at motor parks has greatly reduced, though not completely eliminated. Also, there are law enforcement agents monitoring. Thus, it is being implemented, because consumption has reduced, though not totally eliminated Yes, I remember at the first inspection of these Federal Road Safety [meetings] there was a device they were using to detect drivers who consume alcohol, and some state government officials appoint[ed] some people. They gave them special names, and they go to parks and some other market places to make sure they arrest when they see people consuming alcohol excessively, to the extent that they even arrest the people selling the alcohol without any license. And then even those who sell with license, [there] are restrictions as to what type of drinks they can sell to the community. [Representative of the Academic and Medical Sector, code 025] In addition, the media also proposed initiatives to ban alcohol advertisements, and this was successfully implemented in the 1990s during Olikoye Ransome Kuti s tenure as the Minister of Health. However, this has not been sustained due to the business interests and funds generated from advertising alcohol: In the media we have tried as much as possible to push this limit At a point we were actually asking for an outright ban of the advertisement of alcohol on television, they said it should be restricted to radio because nobody could see, and so that will help. But eventually, you know, because of the business interest here and there, they were able to arrival at an agreeable time of 10 o clock. For a long time, when Professor Olikoye Ransom Kuti was the Minister of Health, the advertisement was not run. [Representative of the Media, code 023] As stipulated in the 2007 Federal Road Safety Act, funding for implementation of the actions will be through the FRSC and consists of any subvention or budgetary allocation; advances and loans from the federal government; money granted to the commission by the federal government from time to time; or monies realized by the commission by way of fines, gifts, grants-in-aid or testamentary disposition to the commission. In reality, funding for these activities has been minimal: I don t think we have any [funding for alcohol policy], I don t think so. Our own budgetary allocation for those items are almost [nonexistent] The funding is not there for drugs, especially narcotic[s]. Yes, I know there is a lot of international collaboration to stamp out illicit 38 Analysis of Non-communicable Diseases Prevention Policies in Nigeria 2017

53 drug use, but not directly alcohol, so the funding is not there and it is not good. [Member, House of Representative, code 011] 3.6. Nutrition and unhealthy diet Unhealthy diet policy context and history Global context Overnutrition is an emerging problem in Nigeria, particularly where lifestyles became urbanized and westernized. Nigeria is a WHO member countries that endorsed the Global Strategy on Diet, Physical Activity and Health, and strongly commitedto addressing unhealthy diets. In spite of this, a recent review (Lachat et al., 2013) shows that policy responses to current NCD challenges through diet and physical inactivity are inadequate in many low middle income countries (LMICs), Nigeria included (Lachat et al. 2013; World Health Organization 2004). The review further identified Nigeria as one LMICs with no clear NCD reduction policy strategies to reduce intake of salt and fat or increase fruits and vegetables (Lachat et al ). Clearly Nigeria s participation in several global meetings to tackle the growing burden of NCDs using nutrition initiatives had no significant influence on the nutrition policies developed in the country prior to the United Nations General Assembly (UNGA) in Consequent to Nigeria s participation in the 2011 UN high-level meeting, the NCD unit of the FMOH developed the National Policy and Strategic Plan of Action on NCDs, which outlines the development and dissemination of the nutritional guidelines as a key action in tackling the rising burden of nutrition-related NCDs. In line with this, the NCD Unit developed and published the National Nutritional Guideline on Non-communicable Disease Prevention, Control and Management (Federal Ministry of Health 2014b) to provide nutrition information and knowledge essential to NCD prevention and management. Communication and information strategies for the promotion of healthy diet is a best buy intervention. The WHO 2010 Global Status Report highlights the development and dissemination of food-based dietary guidelines to consumers as a measure to prevent NCDs and promote healthy diets (World Health Organisation 2010a). Nigeria also developed the National Strategic Plan of Action for Nutrition ( ) for the Health Sector Component of National Food and Nutrition Policy (Federal Ministry of Health 2014a). The rationale for the policy documents developed in the past five years stem largely from the growing burden of nutrition-related NCDs; the participation of the president and high-level FMOH officials at the 2011 UN high-level meeting and other relevant WHO forums; as well as the global movement to address NCDs. The quotes below underscores this: Yes, the rationale is derived from information from WHO. Lke I said earlier, WHO is responsible for the global health of people. [They] discovered cases of obesity, cases of diabetes that they attribute to unhealthy consumption of diet. Most countries, including Nigeria, were involved in various summit[s] organized by WHO to have what we call global legislation on healthy diet. [Representative of the Academic and Medical Sector, code 025] The rationale is the increasing presence of NCDs, which are preventable through what we eat, or the aggravation can be ameliorated through what we eat. The government now knows that not all diseases need medication or therapy, but proper and adequate nutrition. [Representative of Professional body, code 018] Local context The review by Lachat et al., 2013 showed the disconnect between the NCD burden and national policy responses in many LMICs, including Nigeria. Key factors accounting for this finding in Nigeria include the high prevalence of under-nutrition according to Demographic and Health Analysis of Non-communicable Diseases Prevention Policies in Nigeria

54 Surveys (DHS) for Nigeria. Unfortunately, the DHS focus largely on nutrition among children under five and women of reproductive age and do not represent those who are not in these age brackets. Another key factor is donor interest in funding child nutrition initiatives. This is a typical situation that occurs in many LMICs and largely depends on external donor funding, which undermines national efforts to holistically address nutrition and health. Prior to Nigeria s endorsement of the Global Strategy on Diet, Physical Activity and Health at the 2011 UNGA, the National Population Commission developed two key documents: the National Policy on Food and Nutrition in Nigeria (2001) and the National Plan of Action on Food and Nutrition in Nigeria (2005) (National Planning Commission 2001; National Planning Commission 2005). The development and implementation of these policies was largely driven by donor funding and interest. The food regulatory agency in Nigeria, the National Agency for Food Drug Administration and Control (NAFDAC), also has regulations and guidelines to regulate the food and beverage industries, however, these do not specifically target NCDs prevention. Relevant regulations and guidelines developed by NAFDAC include the 2005 Fruit Juice and Nectar Regulations, 2005 Food Grade (Table or Cooking) Salt Regulations 2005, and the 2005 Fats and Oils Regulations (National Agency for Food and Druc Administration and Control 2005b; National Agency for Food and Druc Administration and Control 2005a)(National Agency for Food and Druc Administration and Control 2005b; National Agency for Food and Druc Administration and Control 2005a)(National Agency for Food and Druc Administration and Control 2005b; National Agency for Food and Druc Administration and Control 2005a)(National Agency for Food and Druc Administration and Control 2005b; National Agency for Food and Druc Administration and Control 2005a)(National Agency for Food and Druc Administration and Control 2005b; National Agency for Food and Druc Administration and Control 2005a)(National Agency for Food and Druc Administration and Control 2005b; National Agency for Food and Druc Administration and Control 2005a)(National Agency for Food Drug Administration and Control 2005; National Agency for Food and Drug Administration and Control 2005b; National Agency for Food and Drug Administration and Control 2005a). This development was driven by the need to have regulatory guidelines for the manufacturers of these food products. There seems to be a growing realization among stakeholders to tackle diet-related NCDs (DRNCDs) but a critical review of the documents developed before and after the 2011 UNGA reveals substantial gaps in the proposed action to global recommendations addressing unhealthy diets, such as regulatory frameworks for industries and taxation. This gap can be attributed to a knowledge deficit among policymakers about the current recommended initiative for reducing unhealthy diet and DRNCDs, or a lack of strong CSOs or donor organizations to drive policy formulation in line with global recommendations for reducing unhealthy diets Policy content and best buys addressed A review of the nutrition-related policy documents, excluding the regulations by NAFDAC, indicates that all best buy interventions are addressed (see Table 12). However, they rely largely on educational interventions for the general population and the development of food-based dietary guidelines, which reflects traditional approaches to addressing lifestyle changes. Research reveals these strategies are limited because environmental context drives individual diets and lifestyles, which must be considered for reducing DRNCDs. In addition, policy measures in particular those addressing the private sectors were not clearly outlined in the policies (Lachat et al. 2013). The overall goal for the development of Nigeria s Food and Nutrition Policy (2001) is the improvement of nutritional status for all Nigerians, with particular emphasis on the most vulnerable groups: children, women and the elderly. The National Plan of Action on Food and Nutrition in Nigeria (2005) enumerates set strategies and projects for improving the nutritional 40 Analysis of Non-communicable Diseases Prevention Policies in Nigeria 2017

55 status of all Nigerians, with specific emphasis on the most vulnerable groups. Its goals are to initiate new program focus, effectively integrating and coordinating all sectors food and nutrition programs. Furthermore, it advances a national nutrition agenda that effectively recognizes and responds to regional, zonal, and specific needs in accordance with the National Policy on Food and Nutrition in Nigeria. The identified intervention programs articulated in this document were based on objectives from the 2001 National Policy on Food and Nutrition. The interventions proposed in the Food and Nutrition Policy (2001) and the National Plan of Action on Food and Nutrition in Nigeria (2005) include promoting healthy lifestyles and dietary habits. Specific actions include: developing and disseminating dietary guidelines for all age groups; implementing and supporting community-based nutrition education programs; promoting, protecting and supporting breastfeeding and adequate complementary feeding practices; and creating awareness of malnutrition and DRNCDs using mass media such as radio, TV, drama, film documentary, home video, and posters in local languages. The National Nutritional Guideline on NCD Prevention, Control and Management provides information and knowledge on good nutrition essential to NCD prevention and management. One section discusses the importance of Nigeria having policies to promote healthy diets such as legislation and regulations to reduce trans-fat and salt intake by working with manufacturers and the food-production industry to ensure healthy food supply as well as the importance of adopting a multi-sectoral approach to NCD prevention and control by involving line ministries, civil society organizations and the private sector. These are recommended actions to stimulate the development of appropriate policies by relevant government ministries and agencies. The National Strategic Plan of Action for Nutrition ( ) for the Health Sector Component of the National Food and Nutrition Policy aims to build on the framework outlined in the National Food and Nutrition Policy to improve nutritional status throughout the lifecycle of the Nigerian people, with a particular focus on vulnerable groups, including women of reproductive age and children under five. The proposed DRNCDs interventions target both the community and the health system. Community actions proposed include promoting DRNCD awareness through community structures; establishing and strengthening support groups to promote DRNCD awareness and healthy lifestyles; providing assessment, referral, and counseling through community structures; update/develop, print, and disseminate training materials for Community Health Workers and community peer counselors on DRNCDs; train community resource persons and volunteers on DRNCD and healthy lifestyle choices; conduct advocacy visits on nutrition programs to key decision-makers, opinion leaders, and traditional community leaders to generate demand for nutrition services; mobilize and sensitize community leaders on DRNCDs; conduct formative assessments to determine best practices, lessons learnt, and potential strategies for behavior change communication (BCC) in Nigeria; develop and tailor BCC strategies and dissemination methods; assess dietary diversification and food fortification practice in the community; assess knowledge, attitudes, and practice on proper food-handling and preparation; and develop a community information board to monitor nutrition interventions at community level. Others include building the capacity of media personnel on DRNCD causes and consequences of unhealthy and sedentary lifestyles as well as creating and institutionalizing a National Nutrition Day. The 2005 Fruit Juice and Nectar Regulations, 2005 Food Grade (Table or Cooking) Salt Regulations 2005 and the 2005 Fats and Oils Regulations were designed to guide food product manufacture in Nigeria. These regulations do not have policy actions directed towards NCD prevention. The 2005 Food Grade (Table or Cooking) Salt Regulations 2005 and the 2005 Fats and Oils Regulations only specify information for the production of salt, fats and oils in Nigeria. It does not provide information on the salt or transfat content of manufactured or processed food. On the other hand, the 2005 Fruit Juice and Nectar Regulations specify the maximum quantity of added sugar for fruit juices and nectars produced in Nigeria. However, it does not indicate the sugar content specification for other food products and beverages. Analysis of Non-communicable Diseases Prevention Policies in Nigeria

56 A review of these documents reveals that there is a skewed emphasis on under-nutrition, largely because it significantly contributes to the burden of disease and death among children. Most of the donors who facilitated the policy development processes have a bias for this vulnerable group. Table 12: Nutrition policies, the best buys addressed and year of development Policy document and year National Policy on Food and Nutrition in Nigeria, 2001 Main goal Best buy addressed Best buy emphasis; extent of implementation To improve the nutritional status of all Nigerians, with particular emphasis on the most vulnerable groups Reduced salt intake in food; replace trans-fat with polyunsaturated fat; public awareness through mass media; Low National Plan of Action on Food and Nutrition in Nigeria, 2005 To initiate program focus, effectively integrate and coordinate all sectors food and nutrition programs reduced salt intake in food; replace trans-fat with polyunsaturated fat; raise public awareness through mass media on diet Low National Policy and Strategic Plan of Action on NCDs, 2013 and 2015 To promote healthy lifestyles in Nigeria and provide a framework for strengthening the health care system using MSA for prevention and control of NCDs Reduced salt intake in food; replace trans-fat with polyunsaturated fat; public awareness through mass media Moderate National Nutritional Guideline on NCDs Prevention, Control and Management, 2014 To provide essential information and knowledge on good nutrition for NCD prevention and management Reduced salt intake in food; replace trans-fat with polyunsaturated fat Low National Strategic Plan of Action for Nutrition ( ) for the Health Sector Component of National Food and Nutrition Policy To build upon the framework outlined in the National Food and Nutrition Policy to improve the nutritional status throughout the lifecycle of Nigerian people, with a particular focus on vulnerable groups Public awareness through mass media on diet Low Fruit Juice and Nectar Regulations, 2005 To guide the manufacturing of food products in Nigeria None None Food Grade (Table or Cooking) Salt Regulations, 2005 To guide the manufacturing of food products in Nigeria None None Fats and Oils Regulations, 2005 To guide the manufacturing of food products in Nigeria None None Policy process The development of nutrition policies for Nigeria predates the 2011 UN high-level meeting on NCDs. Prior to 1990, food and nutrition activities in Nigeria were carried out by sector, resulting in several policies addressing food and nutrition concerns in different development sectors. These activities were limited in scope, uncoordinated, and largely ineffective in comprehensively addressing nutritional problems (FMOH 2014a). In response, in 1990 the Federal Government of Nigeria established a National Committee on Food and Nutrition (NCFN) as an institutional arrangement to coordinate and provide leadership on comprehensive policy actions that could 42 Analysis of Non-communicable Diseases Prevention Policies in Nigeria 2017

57 effectively reduce or eliminate malnutrition in Nigeria. NCFN is a multi-sectoral, multi-stakeholder platform that engages several line ministries and leads nutrition policy development using a consultative approach and stakeholder involvement (FMOH 2014a). NCFN isdomiciled at the National Population Commission and comprises representatives of various government ministries and external stakeholder groups. In 1995, the National Planning Commission formulated a National Food and Nutrition Policy (NFNP), which the Federal Government approved in The National Policy on Food and Nutrition in Nigeria (2002) launched in November 2002, and subsequently in 2005 became known as the National Plan of Action on Food and Nutrition in Nigeria. It details strategies for the 2001 National Policy on Food and Nutrition in Nigeria. Nigeria also has a Nutrition Partners Forum, which is chaired by the Head of the Department of Family Health, FMOH. They meet at least four times a year to discuss strategy development and undertake decisions relating to funding and nutrition emergencies in Nigeria. Current policies focusing on NCD prevention and control through promotion of healthy diets, specifically the 2014 National Nutritional Guideline on NCD Disease Prevention, Control and Management and the National Strategic Plan of Action for Nutrition ( ) for the Health Sector Component of National Food and Nutrition, were developed by the NCD and nutrition unit of the FMOH, respectively (FMOH 2014b; FMOH 2014a). The process of developing the two documents was not as consultative as documents produced by the NCFN. This could be attributed to low prioritization and a lack of understanding the importance of involving other sectors, as well as low funding support from donors and the government budgetary allocation Multi-sectoral involvement The Food and Nutrition Policy (2001) and the National Plan of Action on Food and Nutrition in Nigeria (2005) were developed through a consultative MSA. Representatives of ministries who participated in its development were: Health (Food and Drug Services department and Nutrition division); Women Affairs and Youth Development; Industry; Finance; Education; Information and National Orientation; Science and Technology; Agriculture and Rural Development. Others include federal agencies such as National Agency for Food and Drug Administration and Control (NAFDAC); National Primary Health Care Development Agency (NPHCDA); and academia and professional body of nutritionists (Nutrition Society of Nigeria). International organizations that participated in the process were: the United Nations Children s Fund (UNICEF), United States Agency for International Development (USAID), POLICY Project, Basic Support for Institutionalizing Child Survival (BASICS II), Helen Keller International (HKI), Johns Hopkins University/Health Communication Project (JHU/HCP), International Institute of Tropical Agriculture (IITA), Food and Agriculture Organization and the World Bank, details in Table 13. The Nutrition and NCDs Control Division of the FMOH provided leadership support for the development of the 2014 National Nutritional Guideline on NCD Prevention, Control and Management and the National Strategic Plan of Action for Nutrition ( ) for the Health Sector Component of National Food and Nutrition Policy, respectively. Although some were involved, the process did not involve extensive stakeholder involvement compared with documents developed by NCFN. For instance, representatives of the FMOH, National Primary Health Care Development Agency, 36 state nutrition officers, UNICEF, Clinton Health Access Initiative (CHAI), World Bank, Save the Children, academia and professional bodies developed the National Strategic Plan of Action for Nutrition ( ) for the Health Sector Component of National Food and Nutrition Policy, but relevant government MDAs such as NAFDAC, Agriculture, Education, Women Affairs, Information were not involved, despite proposed actions that have an implementation role. In addition, the National Nutritional Guideline on NCD Prevention, Control and Management was developed by professionals drawn from the health sector, namely, NCD experts, Federal and State Ministries of Health officials, and a member of the Nigerian Society of Nutrition. A quote from a respondent underscores this: Analysis of Non-communicable Diseases Prevention Policies in Nigeria

58 Again, during the meeting [for the development of the National Nutritional Guideline on NCD Prevention] it was very obvious we probably may not get it right until we [involve more sectors]. There was a lady actually from the ministry, although she is in the public health department, I think she is a nutritionist, she said we needed a bigger society, like Nigerian nutritionist society. We need food industry because for now I don t know how reliable our food labelling is, so I think we also need NAFDAC. We also need standard organizations of Nigeria, all [these] organizations have something to do with food. [Representative of the Academic and Professional Group, code 041] NAFDAC s food regulations and guidelines were ratified by the agency s governing council, which is constituted by an act of government, so MSA was not an underpinning principle. Membership of the governing council include the Director General Standard Organization of Nigeria, National Drug Law Enforcement Agency, Pharmacist Board of Nigeria, Pharmaceutical Group of the Manufacturers Association of Nigeria, Food and Beverages Group of the Manufacturers Association of Nigeria, three others to represent public interest, and the Director General of the Agency. The regulations were developed by NAFDAC with ratification by the governing council and the process did not involve an extensive stakeholder involvement. A critical factor that enhanced MSA in nutrition policy formulation was the establishment of a functional, well-funded multidisciplinary NCFN. Table 13: Level of involvement of organizations in the development of the nutrition policies Organization Food and Nutrition Policy (2001) and the National Plan of Action on Food and Nutrition in Nigeria (2005) National Nutritional Guideline on NCD Prevention, Control and Management National Strategic Plan of Action for Nutrition ( ) for the Health Sector Component of National Food National Food and Nutrition Committee coordinated by the National Planning Commission High they lead the process X X FMOH High Technical experience/expertise High they lead the process High they lead the process Academia and professional groups High- Technical experience/ expertise Moderate-Technical experience/expertise Moderate-Technical experience/expertise International agencies High- Technical experience/ expertise Low-Technical experience/expertise X Religious organization Moderate-Technical experience/expertise X X NGOs Moderate-Technical experience/expertise X X Other government agencies High-Technical experience/ expertise X X X - Not involved 44 Analysis of Non-communicable Diseases Prevention Policies in Nigeria 2017

59 Table 14 presents the MSA rating for the formulation of diverse policies to reduce the consumption of unhealthy diet highlighting: sectors involved, critical sectors that were not involved in the policy formulation process, and MSA rating. Table 14: Scoring of MSA in unhealthy diet policy formulation. Policy Sectors involved Relevant sectors not involved National Policy on Food and Nutrition in Nigeria 2001 and National Plan of Action on Food and Nutrition in Nigeria 2005 National Nutritional Guideline on NCD Prevention, Control and Management, 2014 National Strategic Plan of Action for Nutrition ( ) for the Health Sector Component of National Food Fats and Oils Regulations 2005 Food Grade (Table or Cooking) Salt Regulations 2005 Government: ministries of Health, Women Affairs and Youth Development; Industry; Finance; Education, Agriculture and Rural Development, Science and Technology Parastatals: Information and National Orientation, NAFDAC; NPHCDA; National Population Commission Academia and professional body: Nutrition Society of Nigeria Partners: UNICEF; USAID; HKI; JHU/HCP; IITA), Food and Agriculture Organization; World Bank Government: FMOH, Federal Ministry of Agriculture Partner: WHO Professional groups: Diabetes Association of Nigeria, Sickle Cell Foundation of Nigeria, academic and medical sector FMOH, National Primary Health Care Development Agency, state ministries of Health, UNICEF, World Bank, CHAI FMOH, NAFDAC, Standard Organization of Nigeria (SON), National Institute for Pharmaceutical Research and Development, Pharmacists Council of Nigeria (PCN), National Drug Law Enforcement Agency (NDLEA), Pharmaceutical Group and the Food and Beverages Group of the Manufacturers Association of Nigeria Same as above Food Manufacturers Association, hospitality industry, ministries of Information, National Orientation, etc. Agriculture, Information, food industries, NAFDAC, among others MSA Rating High Low Low Moderate Moderate Fruit Juice and Nectar Regulations 2005 Same as above Moderate Facilitators to MSA Political commitment was key facilitator for MSA in policy development and implementation and MSA. The quotes below underscore this: Once you get the political commitment, there is nothing you cannot do in Nigeria what is needed is the political commitment. I believe when they did those health promotions leaflets on NCDs, they had the highest maximum support from the minister, and that s why they were able to bring people together. [FMOH, code 002] Analysis of Non-communicable Diseases Prevention Policies in Nigeria

60 Government establishment multi-sectoral forums or committees, as well as communication and information sharing within the groups, was also identified as a MSA facilitator: The government bringing them together [different sectors] and then exchange of information with one another [enhances MSA]. [Representative of the Media, code 023] Another facilitator for MSA was the importance of involving other sectors to enhance the achievement of set goals in line with global priorities, as expressed in the quote below: Definitely if we don t involve them, we would not be able to achieve our goals and targets, and for us, unless we achieve our goals and targets, we would not have done what the international communities have agreed on. [Representative of the Academic and Professional Group, code 041] Barriers to MSA A major MSA barrier stated by a respondent was the difficulty in reaching consensus: Getting to arrive at a consensus on the right approaches How best can we preach the message? Merely getting the consensus on the various issues posed as a challenge. [FMOH Official, code 002] Implementation status The implementation plan outlined in the National Plan of Action on Food and Nutrition in Nigeria (2005) for DRNCDs has four strategies: use communication packages on food and nutrition for advocacy and behavioral change; incorporate nutrition education in the curricula of primary, secondary, and tertiary institutions; develop and disseminate guidelines on various aspects of food and nutrition; and improve networking and information-sharing among stakeholders. These strategies had 11 activities to be implemented between However, most of the major nutrition interventions implemented in Nigeria focused on undernutrition: What the [FMOH] has been doing in terms of nutrition is really looking at child nutrition, supporting early breastfeeding, exclusive breastfeeding, supplementary feeding, supporting giving people vitamin A and things like nutrition related to the children. That largely is what the nutrition unit of the ministry has been focusing on, you know, nutrition of the child and that of the mother, and the other healthy eating habit has been what the national NCD control program has been championing. [Official of the FMOH, code 002] In time past, there was no serious policy on that [healthy diet], but recently in the last 10 years, the Nigerian government is becoming aware of the importance of healthy diet in promoting good health and longevity. [Representative of Professional Group, code 018] The National Strategic Plan of Action for Nutrition ( ) for the Health Sector Component of National Food and Nutrition Policy has no implementation plan although activities are outlined. Extent of implementation remains low. Nigeria developed dietary guidelines regarding salt intake (WHO, 2006) although implementation and enforcement is low. This situation is further compounded by Nigerians poor level of interest and comprehension of nutrition labels. Nigeria has more than nine food laws but their implementation is poor (Ifenkwe, 2012). The extent of implementation of the National Nutritional Guideline on NCD Prevention, Control and Management is also low. For instance, only FMOH interviewees were aware of it and mentioned it as one of the policy documents/guidelines. Furthermore, legislating the food industry to replace trans-fat with polyunsaturated fat is currently weak. 46 Analysis of Non-communicable Diseases Prevention Policies in Nigeria 2017

61 The 2014 Nutritional Guideline proposes several policy and legislative actions to reduce the consumption of foods high in trans fat, although implementation of policy and legislative options is either weak or non-existent. The quotes below underscore this: I have not come across any [policies on unhealthy diets] but the only institution [I] am aware of is NAFDAC, so NAFDAC is the only one [I] am aware of which regulates the food industry generally. NAFDAC as a body, [I] am aware of it; the policy [I] am not... [Representative of a Food Industry, code 043] The policy that guides the industry that I belong to, is the one from my own company A group external auditor comes to check the content of what should be in the product; they come to check whether we are conforming to the rules of what the policy of the company says. For the country, [I] am not aware of that, like I said earlier NAFDAC comes to check at interval, they do come around to check once in a while. [Representative of a Food Industry, code 043] I know that Ministry of Health ordinarily advise on excessive consumption of some dietary component like salt, and those things and again, whether it is something that [has] been to the parliament to [become] law, most likely not, so, again it is poor, poor policy It is not enough for the Minister of Health when he is being interviewed by journalists to say, if you take too much of salt it is not good We see all those nutritional talks here and there. These are the kinds of thing I see, I have not seen any strong policy statement. [Member, House of Representative, code 011] Yes, we influence the industry with our own regulation by giving them standards or guidelines to check their products. Occasionally we withdraw their products. [Official of NAFDAC, code 009] Public awareness on healthy diets through mass media is another best buy intervention, however, awareness programs on healthy diets are unfocused, one-off events that do not have the potential to motivate or sustain positive behavioral changes. This quote supports this point: I am not even aware of any awareness program about the importance of eating healthy food. [Representative of Academic and Medical Sector, code 025] The financing plan proposed in the National Policy and Strategic Plan of Action on NCDs include funding from governments, private organizations and development partners. However, funding for the implementation of policies and programs is minimal, as this quote shows: Again, funding is minimal. When you asked of funding, my mind goes to the line items that have been budgeted for health. I try to look at it whether there is something, I can t really [find any] because I have taken my time to really study the health budget I have not really seen anything like that [budget for activities aimed at promoting healthy diets], but we have a budget from the NAFDAC. [Member, House of Representative, code 011] The M&E plan of the National Plan of Action on Food and Nutrition in Nigeria (2005) is outlined. Target 6 of the document is aimed to reduce DRNCDs 25% by According to the M&E plan, input and output indicators will be used. M&E is regularly carried out at the community, local government, state and national levels on a regular basis. An efficient and effective management information system (MIS), as well as surveillance systems, monitors and evaluates project performance. The system is supported by appropriate information technology to compile and analyze data and relevant statistics on the programs/projects. It is intended that incentives/rewards are provided for successful implementations while sanction methods are applied against those entrusted with management of failed programs. For efficiency, a logical framework for M&E is prepared for all program areas/ activities before funds are released. Analysis of Non-communicable Diseases Prevention Policies in Nigeria

62 Evidence from Nigeria Demographic Health Survey (NDHS) 2013 suggests the evaluation of some aspects of the National Plan of Action on Food and Nutrition in Nigeria (National Population Commission Nigeria and ICF International 2013). The National Nutritional Guideline on NCDs Prevention, Control and Management has no M&E framework but recommends incorporation in relevant policies for promoting healthy diet Physical activity policy Physical activity policy context and history Sedentary lifestyles from increasing urbanization and mechanization are progressively increasing among the general population in Nigeria. The National Sports Commission developed the National Sports Policy in 2009 (National Sports Commission, 2009). The formulation of Nigeria s sports policy started after independence when sports were brought more into focus and under direct government control at ministerial level. Other factors included recognition of physical education as an academic discipline in the early 1970s, with a distinct body of knowledge and research challenges (Aibueku, Ogbouma 2014). This landmark recognition led to the emergence of physical and health education departments in several Nigerian higher learning institutions. The direct consequence was the emergence of a corps of professional physical educators. Consequently, the government invested huge sums into the organization of sports festivals andschools sports; increased sports event funding as well as engaging in capital intensive construction of sports facilities (Aibueku SO, Ogbouma 2014). Although commendable, this policy document focuses largely on sports and not comprehensive actions aimed at reducing physical inactivity and remains a challenge at promoting physical activity. Other policy documents that have policy elements aimed at increasing physical activity include the National School Health Policy (2006), developed by the Federal Ministry of Education; and the National Health Promotion Policy (2006), developed by the FMOH. Despite Nigeria s endorsement of the Global Strategy on Diet, Physical Activity and Health, there is a disconnect between proposed global recommended actions and policy actions proposed in the Nigeria sports policies. With the realization of the growing burden of NCDs and the potential contribution of sporting activities to reduce the prevalence of NCDs, the officials of the National Sports Commission commenced the development of a policy document Health Benefit of Exercise, but feedback from anecdotal sources indicated this document was not published and currently does not top the agency s priority list. Outlined below is a quote from an official of the sport agency when asked about the rationale of Health Benefit of Exercise : It is the realization that that is the only way to go if we do not want to get into an epidemic situation with NCD, it is the realization that We are in a transitional society, we are moving from being physically active to sedentary and modern life that is automated. We see that the epidemiology of diseases in Nigeria is changing from communicable disease to NCD. We also begin to see that what before we [thought was] limited to the Western world is here with us, so we realize that this is extremely important. And then for us, we are in [the] business of physical activity, because we are in sport, so this falls in our domain. [Representative of the Sports Sector, code 029] Policy content and best buys addressed The philosophy of the National Sports Policy is to encourage participation in sport for enhancement of health, exhibition of innate physical attributes, expression of talents, skills, and alleviation of poverty. The policy outlined is broad and diverse, ranging from athlete identification, personnel training, security, and more. The policy has 15 objectives and only one directly promotes physical activity (objective 1). In addition, three of the 15 policy objectives address interventions 48 Analysis of Non-communicable Diseases Prevention Policies in Nigeria 2017

63 that have potential to improve physical activity. The policy: encourages mass participation in sports and recreation with a view to using exercise for the improvement of the general health and fitness of citizens; encourages provision of recreational and sporting facilities by the three tiers of government; promotes school and institutional sports development and competitions at all three tiers of government; and ensures that sports are an integral part of the curriculum at all education levels (nursery, primary, secondary and tertiary) and institutions. Specific strategies with potential to improve physical activity levels as outlined in the policy are: encourage development of physical education and sports in schools; ensure sports is offered as compulsory subjects at nursery, primary, secondary levels of the formal education system; ensure all primary and secondary schools have playgrounds for sports; ensure all schools establish a structured sporting program that covers every student except those exempted on medical grounds; ensure any student studying in any institution of higher learning offers a minimum of a 4-credit unit course in sports; and provides community-based sports centers. The School Health Policy (2006) explicitly states that the Federal Ministry of Education, in collaboration with the Ministry of Sports and Social Development, creates awareness on contemporary health issues; employs sports to handle remediable problems of school children; mobilizes schools to use sports as a channel to divert children from unwholesome practices; mobilizes children to overcome academic stress through sport; builds capacity of personnel to supervise sporting activities in schools; designs sporting activities in school; and ensures the development and execution of relevant recreational activities for the health benefits of the school community (Federal Ministry of Education 2006). Several activities and strategies are outlined in the policy documents but none proposed any best buy strategies. Details in Table 15. Table 15: Physical activity policies Policy Best buy addressed Year of development Source of Information (reference number or interviewee code) National Sports Policy None 2009 National Sports Policy School Health Policy None 2006 School Health Policy Implementation Guidelines on National School Health Program None 2006 Implementation guidelines on National School Health Program A significant proportion of the interviewees were unaware of any physical activity policies although they stated there were some workplace interventions to promote physical activity. The increasing level of workplace interventions is linked to the rising number of NCD deaths among the productive age group and the increasing awareness about physical activity for public health promotion. I don t think there is a policy but government have done some enlightenment on the need for exercise and also on the need for healthy living. [Representative of Professional Body, code 012] I am sure there is also WHO guideline on physical inactivity which they try to push in all countries of the world. I don t think we have any policy statement or even bill that talk about this. [Member, House of Representative, code 011] No, but when we look at sport, we might see policy on physical activities. Apart from that, I am not aware of any policy However, programs and activities that encourage physical activity are available, for instance, in the [Federal Ministry of Education] there is a monthly jogging which has been institutionalized and certain organizations and doctors encourage people to engage in physical activity. [Official of the Federal Ministry of Education, code 005]. Analysis of Non-communicable Diseases Prevention Policies in Nigeria

64 Policy process Nigeria has concise policies on sport that mainstreamed into the National School Health Policy and its implementation guideline. These documents, specifically the National Sports Policy (2009), School Health Policy (2006) and Implementation Guidelines (2006), predate the 2011 UN high-level meeting on NCDs. The policy thrust is the use of sports as a way to promote education, recreation, healthy development, interscholastic competitions and prevent anti-social behaviors. Invariably, physical activity interventions to reduce the NCD burden do not prominently feature. Specific processes adopted for the policy include the inauguration of a 12-person committee to spearhead the effort. This approach was neither consultative nor multi-sectoral. The School Health policy adopted a multi-sectoral process with representatives from diverse sectors such as the federal ministries of Health, Environment, Water Resources, Agriculture and Rural Development, Information and National Orientation, State Universal Basic Education Board (SUBEB), National School Health Association, Pediatric Association of Nigeria, National Association of Parent Teachers, and WHO, among others who participated in meetings organized by the Federal Ministry of Education to develop the document Multi-sectoral involvement The development of the sports policy was led by the National Sports Commission. However, a review of the process shows MSA use was low. According to a representative of the sports agency in answer to the question how did they involve other sectors in policy development? : Well, we have no experience [in bring other sectors together], we just started. But in other places, this is exactly what they did. They get all the relevant stakeholders because that is the only way, otherwise they won t buy into it. [Representative of the Sports sector, code 029] The use of MSA in the National School Health Policy 2006 and Implementation Guidelines on National School Health Program is high, as revealed by the stakeholders who participated in the process Barriers to physical activity policy formulation Major barriers to physical activity policy formulation include lack of experience with MSA; a poor understanding of actions proposed for reducing insufficient physical activity among relevant stakeholders; and a lack of prioritization for physical activity policies by sports sector officials. Others include developing a physical activity policy to effectively address the insufficient physical activity of the large Nigerian population and getting political buy-in and support for the process. This is expressed in the quote below: We have challenges of getting a policy that will cover the population of 170 million. It requires a lot because we have to get a target population which in the whole country we have to get the political heads to buy into the policy and give it political support and the framework, we have to get those who are going to eventually operate this policy, drive it, trained and able to drive it. So, it is a complicated situation. [Representative of the Sport Sector, code 029] Implementation status None of the policy documents have implementation plans for promoting physical activity. The M&E plan for the National Sport Policy was not stated. The National School Health Policy states that M&E committees will be constituted at all levels and will be responsible for the overall 50 Analysis of Non-communicable Diseases Prevention Policies in Nigeria 2017

65 supervision and M&E efforts leading to a healthy school environment. The committee collaborates with relevant agencies in the inspection and enforcement of necessary sanctions as related to: appropriateness of the location and size of the school, availability of recreation facilities, and physical structures and buildings. Although Sports Policy objectives are desirable for promoting physical activity, there is a dearth of information on the implementation of this policy (Nigerian Heart Foundation 2013). According to quote from the Minster of Sports in a newspaper report published in 2016, the implementation of the 2009 sports was poor. Analysis of Non-communicable Diseases Prevention Policies in Nigeria

66 Discussion 4.0 Discussion

67 In this study, we assessed the extent of MSA use in formulating and implementing NCD prevention policies for insufficient physical activity, unhealthy diet, harmful use of alcohol and tobacco use, as well as the extent of integration of the WHO best buy interventions in the policies. We also identified the enablers and barriers to the MSA use. Nigeria has 17 NCDrelated policy documents and this section discusses the gaps in NCD policy and MSA approach; significant facilitators and barriers to NCD policy development; and recommendations Gaps in NCD policy Nigeria made significant progress in implementing recommended NCD actions by developing the National Policy and Strategic Plan of Action on NCDs, which proposes actions for the four major NCDs: cardiovascular diseases, cancers, chronic respiratory diseases and diabetes; and the four modifiable risk factors: tobacco use, harmful alcohol use, unhealthy diet and physical inactivity. However, significant gaps regarding policies for harmful alcohol use, unhealthy diets, and physical inactivity exist. Neglect of the alcohol policy has a long history: So far, alcohol has not received the attention it deserves in Nigeria. It is increasingly abused. This abuse will become a serious problem within the next few years since the prohibition on the formally illicit locally brewed gin has been lifted beer breweries proliferated apparently for political purposes. Local distilling of gin has recently received government blessing; bottling of imported spirits is very common now; the indigenous palm wine is gradually disappearing from the cities where more potent alcohol is being used (Anumonye, Omoniwa and Adaranijo 1977). Unfortunately, successive Nigerian governments continue to shun regulation of harmful alcohol use (Oluwaniyi 2010). Nigeria s alcohol industry used the strategic ambiguity concept to undermine alcohol policy efforts; organizations with vested interests and multiple goals can use ambiguous symbols or words with a potential to undermine the clarity of messages (Dumbili 2014). For instance, the brewers and ICAP collaborated with FRSC in its campaign in which drivers are advised to drink responsibly instead of adopting the WHO recommendation of don t drink if driving strategy. In addition, there is no clear definition of responsible drinking by the government due to a lack of definition of standard drinks. In addition, the alcohol industry leveraged the influence of culture, tradition and deference to traditional rulers as a marketing and promotion strategy in countries. For instance, for decades Seaman s Schnapps advertised as a libation drink while Orijin, an herbal drink with 6% alcohol content, introduced in Nigeria in 2013, was launched across the country in the palaces of high chiefs (Obot, 2015), although a second version without alcohol is currently in the market. These findings reveal the significant gaps in the development and implementation of policy on the harmful use of alcohol in Nigeria. Interventions used in other countries to reduce consumption of industrially produced trans fats are included in mandatory regulation of food standards, nutritional recommendations, raising awareness about adverse effects of trans fats and labelling of trans fats content of foods (Stender et al. 2009). Industry reformulation and bans are the most effective action (World Health Organization 2010a). However, in Nigeria, legislation to mandate the food industry are currently weak. Furthermore, the sport policy developed by the Federal Ministry of Sports does not adequately address insufficient physical activity, but instead emphasizes sports development for recreation and competition (National Sports Commission 2009). This gap can be linked to the inaccurate perception among bureaucrats and the general public that physical activity/exercise is only for recreation or controlling obesity. It is invariably regarded as a minor or secondary risk factor for NCDs, therefore its relevance for NCD prevention and intervention is undermined, especially in Analysis of Non-communicable Diseases Prevention Policies in Nigeria

68 LMICs (Das & Horton 2012). There is a need to reorient relevant stakeholders on the importance of physical activity for health as well as MSA to promote physical activity. The comparative success achieved with tobacco control policies can be attributed to the historical context spanning several years, with in-built MSA that enriched the process, outcomes, high level of activism, and donor interest (Drope 2011). Lessons learnt from the process can be harnessed and transferred to other NCD risk factors in order to fast-track the policy formulation. This would involve building a critical mass of advocates consisting of the civil society, academia/ researchers, and professional associations to canvass for policy development and enactment in line with the MSA principle and WHO best buys, similar to approaches used in building the capacity of CSOs in the WHO European region to advocate NCD-related issues (NCD Alliance, n.d.). The need is increasing for further research to quantify these risk factors contributions to Nigeria s NCD burden. The publication of the draft NCD policy and action plan online with major editorial faults seems to reflect the low importance attached to such an important publication and the quality of technical assistance provided. An additional concern is why the policy documents have not been disseminated to the states and local government areas (LGAs). Lack of significant government funding to support the process and the over-dependency on donor organizations were of concern, reflecting a lack of sustained leadership and strong political will a prerequisite for effective implementation of the stepwise approach of priority policies and programs (Beaglehole, Bonita, Horton 2011). On a positive note, NCD-related policies in different sectors are due for review. This presents unique opportunities to mainstream the best buy interventions and ensure the policy actions align to those outlined in the National Policy and Strategic Plan of Action on NCDs Gaps in MSA approach In spite of its relative importance, the extent of MSA for NCD policy formulation in Nigeria is low, except for tobacco use. High-level political leadership has the authority and resources, monitors progress and ensures adherence to international commitments, which are the most critical element of an effective NCDmulti-sectoral coordination mechanism (WHO 2015). Therefore a critical step to galvanize MSA for NCD prevention in Nigeria requires enlisting high-level political commitment at the supra-ministerial level. It is hoped that WHO s proposed African Region plan to enhance the capacity of bureaucrats in using MSA will go a long way in resolving this challenge. MSA operationalization is fraught with its own potential challenges, especially when different sectors have conflicting objectives about values and diverging interests, economic or otherwise (World Health Organization 2012). An example is the request by a sector (Standard Organization of Nigeria) calling for the involvement of the tobacco industry, contrary to WHO recommendations. The often-conflicting mandates of ministries are an obstacle to coordinated action (WHO 2015) and require a clear-cut government directive to state the country s position on contentious health issues with economic/business implications. Furthermore, ignorance and inexperience about MSA was identified as a barrier, especially with sectors that traditionally excluded health-related multi-sectoral programs. To facilitate MSA in Nigeria, it is critical to identify sectors that lack MSA experience and help them overcome this barrier. This requires a steep learning curve for cross-sectoral alliance-building (World Health Organization 2012) and underscores the need to train policy bureaucrats in MSA knowledge and skills on dialogue, consensus and group dynamics to achieve the common goal (Toro et al., 2006). 54 Analysis of Non-communicable Diseases Prevention Policies in Nigeria 2017

69 Joint resourcing and financing for NCD implementation were identified as potential barriers. Efforts to drive MSA on reproductive health determinants often stalled at implementation phase to operational issues such as financing and MSA joint monitoring, which proved difficult in practice (Rasanathan et al., 2015). This underscores the importance of an effective costsharing mechanism between sectors for specific plan components, supported by autonomous, innovative, public-private financing mechanisms that use tax from tobacco, alcohol, sugar and trans fats, as well as fines, levies and government budgetary allocations. The public-private partnership approach will enhance accountability and judicious use of resources. MSA leadership contentions and governance were also identified as barriers. An example is the situation created by the FMOH s misperception that it needs to anchor all NCD policies and programs. To address this issue, there must be political leadership to drive and coordinate different sectors and actors to work together with joint accountability (Every Woman 2016). Pertinent to this process is the need to develop a pragmatic framework to ensure leadership and accountability are shared among partners. NCD prevention and control requires the involvement and participation of government ministries and the private sector, which can make coordination mechanisms unwieldy and difficult to manage (WHO 2015). This challenge was identified in the study and necessitates a strong secretariat, with its location decided by the level of existing and anticipated political support, ownership of the hosting ministry, and ease of involvement for other sectors (WHO 2015). Another MSA gap is the FMOH practice involving developing policy documents over two to three meetings, using policies from other countries as a template. This has implications for the extent and quality of the multi-stakeholder consultative process, as well as development of appropriate policy actions relevant to Nigeria. This approach also creates a challenge in regards to ownership of the proposed policy actions and willingness of the relevant MDAs in implementing them. It further limits quality consultation and deliberations before appropriate actions are proposed and adopted. If not regulated, the content, quality and implementation of the policy actions stated might be compromised. A further noted challenge is the failure of national levels to orientate the sub-national levels on current global policy directions and actions with regards to NCDs prior to the distribution of policies and strategic action plans. This interferes with the sub-national implementers/ bureaucrats understanding of policy directions, which also affects implementation Most significant facilitators to NCD policy development Participation of high-level officials, especially the president, at high-level global meetings, is crucial for stimulating political commitment and catalyzing follow-up actions, and should be encouraged. Ensuring provision of quality epidemiological evidence for informed decisionmaking at national level and using the media for increasing community awareness on NCD burdens is also key Most significant barriers to NCD policy development Resource requirements for meeting the population s health needs in developing countries is increasing due to the dual burden of communicable and NCDs, therefore additional health sector resources are growing faster than government health expenditures (Management Sciences for Health 2012). This is a major challenge in many developing countries. Despite developing countries increasing double burden, health funders have not yet mobilized the substantial investment required to respond (Maher et al. 2012). Analysis of Non-communicable Diseases Prevention Policies in Nigeria

70 NCD policies underfunding, as reflected in the study, shows that only a third of government health ministries even had a single budget line for NCDs, and less than 3% of global health aid was designated (Yach D. & Hawkes C. 2004; Nugent & Feigl 2010). Furthermore, WHO which provided the strongest support to NCDs among global institutions allocates less than 10% of its budget to these diseases (Stuckler D, King L, Robinson H 2008). This is a major factor hindering NCD policy formulation and implementation in many developing countries, including Nigeria. Over-dependence on donor aid was identified as a barrier for NCD policy development and implementation. Low or non-existent government budgetary allocation to support policy development and implementation is a reoccurring phenomenon that requires urgent attention and could form part of the agenda at global and national meetings, maybe tied to country assistance support from the international community. A mechanism for innovative funding could be introduced wherein government sectors, financial institutions and donor organizations contribute annual specified amounts to a central pot managed by a private sector board. This would ensure availability of funds for NCD policy development and follow-up implementation. Low political priority for NCDs is another barrier (Maher & Sridhar 2012). Despite participation of Nigerian officials at the UN high-level meeting, the political prioritization for NCDs remains low. To advance the NCD agenda, continuous advocacy and pressure to ensure NCDs attain and remain a top political priority is needed. This can be effectively facilitated by the civil society organizations, academia and professional groups, as evidenced by tobacco control in Nigeria (Drope 2011) Limitations The conduct of the data collection phase of study was fraught with challenges due to the country experiencing an Ebola outbreak. Some policy actors left the country and could not be reached; it was also difficult to reach others due to busy schedules in controlling the epidemic. Furthermore, most actors did not have copies of the policies, which made it difficult to provide the required documents. One sector respondent said research is of no importance to their ministry and refused to participate in the study. 56 Analysis of Non-communicable Diseases Prevention Policies in Nigeria 2017

71 Conclusions 5.0 Conclusions

72 Nigeria contributes substantially to the burden of NCDs in Africa and globally. It has developed some NCD prevention policies, but gaps exist that have critical implications for the prevention. Tobacco use is the only modifiable risk factor with the most comprehensive set of policy actions that aligns with global recommendations and WHO best buy interventions. Harmful use of alcohol has no comprehensive health sector-driven policy to regulate its marketing, advertising and availability. Legal acts to regulate the food industry with regards to the sugar, salt and trans fat content of manufactured foods are nonexistent, and interventions proposed are largely educational intervention for the general population. In addition, the best buy for physical activity is not addressed in any policies. The overarching NCDs prevention policy and Strategic Plan of Action is not finalized, produced and distributed to sub-national level to guide actions for NCD prevention. Nigeria is not well-positioned to achieve the milestones and targets outlined in the WHO Global Action Plan for the Prevention and Control of NCDs and the country must intensify its efforts to address these areas of concern. Furthermore, a key message from this study is that the adoption of MSA for NCD policy formulation in Nigeria is not strong, possibly due to poor understanding of the principle. MSA could be attained if high political commitment is ensured, with strong advocacy by the civil society. Overcoming funding constraint necessitates putting innovative funding mechanisms in place. Tackling these barriers is crucial if Nigeria is to avert the consequences of excessive NCD morbidity and mortality. 58 Analysis of Non-communicable Diseases Prevention Policies in Nigeria 2017

73 Recommendations 6.0 Recommendations

74 Based on the findings of this study, the following recommendations are proposed: 1) In line with objective 2 of the Action Plan for the Global Strategy for the Prevention and Control of NCDs, Nigeria should develop a national multi-sectoral framework committee to lead actions for the prevention and control of NCDs; 2) The committee should review and update the policy actions for alcohol, physical activity and healthy diet outlined in the National Policy and Strategic Plan of Action on NCDs and other relevant policies in line with global recommendations proposed in the WHO (2010) Global Strategy (MSA and best buys) to reduce the harmful use of alcohol and the WHO (2004) Global Strategy on Diet, Physical Activity and Health; 3) Nigeria should develop a national multi-sectoral framework committee to lead actions for the prevention and control of NCDs. The committee should review and update the policy actions for alcohol, physical activity and healthy diet outlined in the National Policy and Strategic Plan of Action on NCDs and other relevant policies in line with global recommendations; 4) The Primary Health Care System should be empowered to coordinate the implementation of NCD primary prevention strategies using MSA; 5) Prioritization and funding of best buy interventions for all NCD risk factors by public and private sector should be accorded; 6) Publication and dissemination of the National Policy and Strategic Plan of Action on NCDs to relevant stakeholders and line ministries to guide sector-led responses; implementation should be carried out urgently; 7) Legal acts should be formulated and ratified to regulate the activities of the alcohol and food industries; and 8) Sustained commitment for the prevention and control of NCDs in Nigeria should be maintained. RECOMMENDATIONS 60 Analysis of Non-communicable Diseases Prevention Policies in Nigeria 2017

75 References 7.0 References

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79 56. Obot, I.S., Nigeria: alcohol and society today. Addiction, 102, pp Oluwaniyi OO, Oil and youth militancy in Nigeria s Niger Delta region. Journal of Asian and African Studies, 45(3), pp Onyemelukwe, G.C., National Survey of Non-communicable Diseases 2003 (South- West Zone) on behalf of the Federal Ministry of Helath and the National Expert Commiittee on NCDs., pp Popuation Reference Bureau, WORLD POPULATION DATA SHEET WITH A SPECIAL FOCUS ON HUMAN NEEDS. 60. Premium Newspaper, Nigerian anti-tobacco advocates to push for higher tobacco taxes - Premium Times Nigeria. 61. Public Health Agency of Canada and World Health Organization., Health equity through inter- sectoral action: an analysis of 18 country case studies., p.hp5-67/2008e. 62. Rasanathan, K. et al., Ensuring multisectoral action on the determinants of reproductive, maternal, newborn, child, and adolescent health in the post-2015 era. BMJ (Clinical research ed.), 351(9745), p.h4213. Available at: Standard Organisation of Nigeria, Standard for Tobacco and Tobacco Products - Specifications for Cigarette, 64. Stender, S. et al., Approaches to removing trans fats from the food supply in industrialized and developing countries. European Journal of Clinical Nutrition, 63, pp Stuckler D, King L, Robinson H, M.M., WHO s budgetary allocations and burden of disease: a comparative analysis. The Lancet, 372(9649), pp The Cable, Adewole vows to enforce anti-tobacco act. 67. The Nations Nigeria, FRSC and statutory functions - The Nation Nigeria. 68. Toro, G.A. et al., Using a Multisectoral Approach to Assess HIV / AIDS Services in the Western Region of Puerto Rico., 96(6), pp TumeAhemba, Nigerian state withdraws $23 bln tobacco lawsuit. 70. Walker, A., Nigeria takes on tobacco giants. BBC News. 71. Walt, G. & Gilson, L., Review article Reforming the health sector in developing countries : the central role of policy analysis. Health Policy and Planning, 9(4), pp World Health Organization, Approaches To Establishing Coordination Mechanisms for the Prevention and Control., pp Winkler, V., Lan, Y. & Becher, H., Tobacco prevention policies in west-african countries and their effects on smoking prevalence. BMC Public Health, pp.1 8. Available at: dx.doi.org/ /s z. 74. World Health Organisation, 2008a Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases, Geneva: WHO Press, World Health Organization. 75. World Health Organisation, 2011a. From Burden to Best Buys : Reducing the Economic Impact of Non-Communicable Diseases in Low- and Middle-Income Countries, Analysis of Non-communicable Diseases Prevention Policies in Nigeria

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81 Annexes 8.0 Annexes

82 8.0. Annexes 1. Search terms and syntax for document search 2. List of documents reviewed 3. Key informant interview guide 4. Code book 5. Ethics review certificate 68 Analysis of Non-communicable Diseases Prevention Policies in Nigeria 2017

83 Annex 1: Search terms and syntax for document search Search syntax (Tax or Smoke-free or advertising or promotion or sponsorship or information or warning OR ACCESS) and (TOBACCO) and (Nigeria) and (policy) (Tax or advertising or promotion or sponsorship or information or warning OR access) and (Alcohol) and (Nigeria) and (policy) (salt or transfat or diet or unhealthy diet) and (nutrition) and (Nigeria) and (policy) (Physical activity or Physical inactivity) and (Nigeria) and (policy) (Multi-sectoral Action ) and (TOBACCO) and (Nigeria) and (policy) (Multi-sectoral Action) and (Alcohol) and (Nigeria) and (policy) (Multi-sectoral Action) and (salt or transfat or diet or unhealthy diet) and (nutrition) and (Nigeria) and (policy) (Multi-sectoral Action) and (Physical activity or Physical inactivity) and (Nigeria) and (policy) Google Scholar (Tax or Smoke-free or advertising or promotion or sponsorship or information or warning OR ACCESS) and ( TOBACCO ) and ( Nigeria ) and (policy) (Tax or advertising or promotion or sponsorship or information or warning OR access) and ( Alcohol ) and ( Nigeria ) and (policy) (salt or transfat or diet or unhealthy diet) and (nutrition) and (Nigeria) and (policy) ( Physical activity or Physical inactivity ) and (Nigeria) and (policy) Multi-sectoral Action ) and (TOBACCO) and (Nigeria) and (policy) (Multi-sectoral Action) and (Alcohol) and (Nigeria) and (policy) (Multi-sectoral Action) and (salt or transfat or diet or unhealthy diet) and (nutrition) and (Nigeria) and (policy) (Multi-sectoral Action) and (Physical activity or Physical inactivity) and (Nigeria) and (policy) Science direct (Tax or Smoke-free or advertising or promotion or sponsorship or information or warning OR ACCESS) and (TOBACCO) and (Nigeria) and (policy) (Tax or advertising or promotion or sponsorship or information or warning OR access) and (Alcohol) and (Nigeria) and (policy) (salt or transfat or diet or unhealthy diet) and (nutrition) and (Nigeria) and (policy) (Physical activity or Physical inactivity) and (Nigeria) and (policy) (Multi-sectoral Action ) and (TOBACCO) and (Nigeria) and (policy) Analysis of Non-communicable Diseases Prevention Policies in Nigeria

84 (Multi-sectoral Action) and (Alcohol) and (Nigeria) and (policy) (Multi-sectoral Action) and (salt or transfat or diet or unhealthy diet) and (nutrition) and (Nigeria) and (policy) (Multi-sectoral Action) and (Physical activity or Physical inactivity) and (Nigeria) and (policy) 70 Analysis of Non-communicable Diseases Prevention Policies in Nigeria 2017

85 Annex 2: List of documents reviewed Policy and Strategic Plan of Action on NCDs National Strategic Plan of Action on Prevention and Control of NCDs 3. The Nigeria Tobacco (Control) Act 1990 CAP.T16, 4. The National Tobacco Control Act, 2015, 5. Standards for Tobacco and Tobacco products, 6. Federal Road Safety Commission Act, Health Promotion Policy National School Health Policy School Health Policy Implementation Plan National Policy on Food and Nutrition in Nigeria, National Plan of Action on Food and Nutrition in Nigeria National Nutritional Guideline On NCDs Prevention, Control and Management Health Sector Component of National Food And Nutrition Policy National Strategic Plan Of Action For Nutrition ( ) 14. National Sports Policy, 2009, 15. National Agency for Food Control Administration and Control (2005) Fruit Juice and Nectar Regulations, National Agency for Food Control Administration and Control (2005) Fats and Oils Regulations, National Agency for Food Control Administration and Control (2005) Food Grade (Table or Cooking) Salt Regulations 18. Drope J (2011) Tobacco Control in Africa: People, Politics and Policies, ANTHEM PRESS Tumwine J (2011) Implementation of the Framework Convention on Tobacco Control in Africa: Current Status of Legislation 2011, Int. J. Environ. Res. Public Health, mdpi.com/ /8/11/4312/htm 20. Dumbili E (2012) Changing Patterns of Alcohol Consumption in Nigeria: An Exploration of Responsible factors and Consequences 2013, Medical Sociology online www. medicalsociologyonline.org/resources/vol7iss1/mso-volume-7-issue-1.pdf 21. Nigerian Heart Foundation (2013) Nigerian Report Card on Physical Activity For Children And Youth, 2013 Nigerian Heart Foundation, downloads/2013_nigerian_report_card. 22. Premium Times (2013) Nigerian anti-tobacco advocates to push for higher tobacco taxes, Premium Times, Analysis of Non-communicable Diseases Prevention Policies in Nigeria

86 24. Premium Times (2015)Jonathan signs Tobacco control bill, five others, premiumtimesng.com/news/top-news/ breaking-jonathan-signs-tobacco-controlbill-five-others.html 25. Channels Television (2012)Presidency Did Not Assent To Tobacco Control Bill- Lamwaker, Nigerian Heart Foundation (2013) Nigerian Report Card on Physical Activity For Children And Youth, 2013, pdf 27. Nwhator SO (2012) Nigeria s costly complacency and the global tobacco epidemic, J Public Health Policy, 33(1): doi: /jphp Epub 2011 Dec 15. J Public Health Policy, 33(1): doi: /jphp Epub 2011 Dec Brathwaite R, Addo J, SmeethL, Lock K (2014) A Systematic Review of Tobacco Smoking Prevalence and Description of Tobacco Control Strategies in Sub-Saharan African Countries; 2007 to 2014, PLoS ONE, 10(7): e doi: /journal.pone Agaku et al. (2012) Tobacco control in Nigeria- policy recommendations.,tobacco Induced Diseases, BMC : World Health Organization (2008) WHO REPORT on the global TOBACCO epidemic, 2008, World Health Organization Volker Winkler, Yong Lan1 and Heiko Becher (2015) Tobacco prevention policies in west-african countries and their effects on smoking prevalence,bmc Public Health, DOI /s z 32. World Heatlth Organization (2015) WHO report on the global tobacco epidemic, 2015: Raising taxes on tobacco, Obot I.S (2007) Nigeria: alcohol and society today, Addiction, 102, Obot I.S (2015) Africa faces a growing threat from neo-colonial alcohol marketing, Addiction, 110, , Africa_faces_a_growing_threat_from_neo-colonial_alcohol_marketing 35. WHO (2014) Global Status Report on Alcohol and Health, abuse/publications/global_alcohol_report/en/ 36. WHO Global Status Report on Alcohol and Health (2011) abuse/.../global_alcohol_report/msbgsruprofiles.pdf 37. WHO (2004) Global Status Report on Alcohol Policy 38. Dumbili E W (2014) The Politics of Alcohol Policy in Nigeria: A Critical Analysis of how and why Brewers use Strategic Ambiguity to Supplant Policy Initiatives, Journal of Asian and African studies 49(4): DOI: / Dumbili E W (2012) Drink Responsibly, Die Irresponsibly? The Menace of Inadequate Government Policies to Regulate Alcohol Misuse in Nigeria, British Journal of Arts and Social Sciences, ISSN: , Vol.7 No.I (2012) 40. Thomas F. Babor, Katherine Robaina & David Jernigan (2015) Vested Interests in Addiction Research and Policy The influence of industry actions on the availability of alcoholic beverages in the African region, Addiction, 110, Analysis of Non-communicable Diseases Prevention Policies in Nigeria 2017

87 41. Carl Lachat, Stephen Otchere, Dominique Roberfroid, Abubakari Abdulai, Florencia Maria, Aguirre Seret, Jelena Milesevic, Godfrey Xuereb, Vanessa Candeias, Patrick Kolsteren (2015) Diet and Physical Activity for the Prevention of NCDs in Low- and Middle-Income Countries: A Systematic Policy Review PLoS Med, 10(6): e doi: /journal. pmed The Cable (2016). Adewole vows to enforce anti-tobacco act. adewole-vows-to-enforce-anti-tobacco-act 43. The Nations Nigeria (2015). FRSC and statutory functions - The Nation Nigeria, thenationonlineng.net/frsc-and-statutory-functions/ Analysis of Non-communicable Diseases Prevention Policies in Nigeria

88 Annex 3: Key informant interview guide Introduction Good (morning/afternoon/evening), My name is ; I work for the African Population and Health Research Center. Today I will be conducting research to analyze the non-communicable disease preventions policies in Nigeria. This study aims to understand how policies have been formulated and implemented to prevent NCDs in Nigeria. The major NCDs we are focusing on include cardiovascular diseases (including hypertension), cancers, chronic respiratory diseases and diabetes. The preventive interventions focus on tackling major risk factors. For this study the risk factors we are focusing on include tackling tobacco use, harmful alcohol use, unhealthy diets and physical inactivity. In particular, we would like to understand who and which sectors have been involved with non-communicable disease prevention policy development and implementation in Nigeria. In terms of policy, we are interested in higher level policies such as laws, regulations, national strategic plans, as well as lower level policy guidelines and action plans related to NCD prevention and program implementation strategies. To obtain reliable information we request that you answer the questions that follow as frankly as possible. Your views are important in this research. There is no right or wrong answers. It is your knowledge and opinion that count. The information you give to us will be kept confidential. You will not be identified by name or address in any of the reports we write. The interview will take minutes PLEASE REQUEST INFORMED CONSENT Demographics, TAKE NOTES (identifying information to be kept separate from interview transcripts) Just to confirm that I have your details right: (USE THE SEPARATE FORM TO COMPLETE THE INFORMATION BELOW) a. Participant s name and organization and /contact details (fill in beforehand if possible): b. Participant s title/designation and primary responsibilities: c. What year did you start working in this organization? What year did you start in this particular position? REQUEST TO TURN ON RECORDERS AT THIS POINT Alcohol Policies A. Policy Context 1. What is your opinion on alcohol policy development in this country? a. Which alcohol policies are you aware of in this country? 74 Analysis of Non-communicable Diseases Prevention Policies in Nigeria 2017

89 b. What was the rationale for formulating the alcohol policy? (probe for each policy mentioned) 2. What issues led to the development of the alcohol policies? (For each policy mentioned) a. What issues within Nigeria context that led to development of the policy (Probe for whether there were political changes, health sector reforms, organizational changes, fiscal policies, and changes in government) b. What issues at the Global level influenced the formulation of alcohol policies (probe for global movements, declarations, meetings) B. Actors in policy formulation 3. To what extent were you involved in the formulation of these alcohol policies? (Probe for each policy mentioned) a. What was your role in the formulation of the alcohol policy b. Please describe your experience as you participated in the formulation of the policy (What in your opinion went well? What could have been done differently?) 4. Which other sectors were involved in the formulation of the policies a. Who led the process in formulating the alcohol policies b. What was the role of the sectors that were involved? (Probe for the sectors mentioned) c. Who else should have been involved in your view and why? i. Why do you think they were not involved? ii. What in your view would have been the impact on the policy if they had been involved? d. What strategies were used to bring the different stakeholders/sectors to work together in formulating these alcohol policies? e. What were the challenges encountered in bringing the different sectors together in formulating the alcohol policies? Policy Implementation 5. To what extent have the alcohol policies been implemented (probe for each policy mentioned?) a. How were you involved in the implementation of the alcohol policies? b. Which other sectors/ stakeholders were involved in the implementation? c. Who else should have been involved in your view and why? i. Why do you think they were not involved? ii. What in your view would have been the impact on the policy if they had been involved? d. What factors enabled different sectors to work together in implementing these alcohol policies Analysis of Non-communicable Diseases Prevention Policies in Nigeria

90 e. What were the challenges encountered in implementing the alcohol policies(probe for challenges in bringing several sectors together to support implementation) 6. What were the benefits of involving many actors in policy development processes? a. What losses were incurred from involving many actors? 7. Please comment on how alcohol industry influenced the alcohol policy development process (negatively or positively). a. How did you overcome any challenges that industry interference may have generated? 7. What would you recommend to facilitate the working together of different sectors in formulating/implementing alcohol policies for the future? Probe for recommendations to facilitate different sectors in working together in implementing of alcohol programs? 8. What kind of funding is available for implementation of the alcohol policies mentioned? Probe: For amount of funding; sources of funding Probe: Are there arrangements such as joint budgeting and delegated financing aimed at addressing alcohol issues? Tobacco Use Policies A. Policy Context 1. What is your opinion on tobacco policy development in this country? a. Which tobacco use policies are you aware of in this country? b. What was the rationale for formulating the tobacco policy? (probe for each policy mentioned) c. Are there any policies that you feel should have been developed for Nigeria (which may be available elsewhere)? 2. What issues led to the development of the tobacco policy (For each policy mentioned :) b. What issues within Nigeria context that led to development of the policy (Probe for: whether there were political changes, health sector reforms, Organizational changes, fiscal policies, and changes in government c. What at the Global level influenced the formulation of alcohol policies (probe for global movements, declarations, meetings) d. B. Policy formulation 3. To what extent were you involved in the formulation of these tobacco policies? (Probe for each policy mentioned) a. What was your role in the formulation of the tobacco policy b. Please describe your experience as you participated in the formulation of the policy (What in your opinion went well? What could have been done differently?) 76 Analysis of Non-communicable Diseases Prevention Policies in Nigeria 2017

91 4. Which other sectors were involved in the formulation of the policies a. Who led the process in formulating the tobacco policies b. What was the role of the sectors that were involved?(probe for the sectors mentioned) c. Who else should have been involved in your view and why? i. Why do you think they were not involved? ii. What in your view would have been the impact on the policy if they had been involved? d. What strategies were used to bring the different stakeholders/sectors to work together in formulating these tobacco policies? e. What were the challenges encountered in bringing the different sectors together in formulating the tobacco policies? C. Policy Implementation 5. To what extent have the tobacco policies been implemented (probe for each policy mentioned?) a. How were you involved in the implementation of the tobacco policies? b. Which other sectors/ stakeholders were involved in the implementation of the policies? c. Who else should have been involved in your view and why? i. Why do you think they were not involved? ii. What in your view would have been the impact on the policy if they had been involved? d. What factors enabled different sectors to work together in implementing these tobacco policies e. What were the challenges encountered in implementing the tobacco policies(probe for challenges in bringing several sectors together to support implementation) 8. What were the benefits of involving many actors in the policy development processes? a. What losses were incurred from involving many actors? 9. Please comment on how tobacco industry influenced the tobacco policy development process (negatively or positively). a. How did you overcome any challenges that industry interference may have generated? 7. What would you recommend to facilitate the working of different sectors in formulating / implementing tobacco policies for the future? Probe for recommendations to facilitate different sectors in working together in implementing of tobacco programs? 8. What kind of funding is available for implementation of the tobacco policies mentioned? Probe: For amount of funding; Sources of funding) Probe: Are there arrangements such as joint budgeting and delegated financing aimed at addressing tobacco issues? Analysis of Non-communicable Diseases Prevention Policies in Nigeria

92 Policies Promoting Physical Activity A. Policy Context 1. What is your opinion on policies aimed at promoting physical activity in this country? a. Which physical activity policies are you aware of in this country? b. What was the rationale for formulating the physical activity policy? (probe for each policy mentioned) 2. What issues led to the development of the physical activity policies?(for each policy mentioned) a. What issues within Nigeria context that led to development of the policies on physical activity (Probe for: whether there were political changes, health sector reforms, Organizational changes, fiscal policies, and changes in government b. What issues at Global level influenced the formulation of physical activity policies (probe for global movements, declarations, meetings) B. Actors in policy formulation 3. To what extent were you involved in the formulation of these physical activity policies? (Probe for each policy mentioned) a. What was your role in the formulation of the physical activity policy b. Please describe your experience as you participated in the formulation of the policy (What in your opinion went well? What could have been done differently?) 4. Which other sectors were involved in the formulation of the physical activity policies i. Who led the process in formulating the physical activity policies ii. What was the role of the sectors that were involved in the formulation of the policies? (Probe for the sectors mentioned) iii. Who else should have been involved in your view and why? i. Why do you think they were not involved? ii. What in your view would have been the impact on the policy if they had been involved? iv. What strategies were used to bring the different stakeholders/sectors to work together in formulating these promoting physical activity policies? v. What were the challenges encountered in bringing together the different sectors in formulating the promoting physical activity policies? C. Policy Implementation 5. To what extent have the p physical activity policies been implemented (probe for each policy mentioned?) f. How were you involved in the implementation of the promoting physical activity policies? g. Which other sectors/ stakeholders were involved in the implementation? 78 Analysis of Non-communicable Diseases Prevention Policies in Nigeria 2017

93 h. Who else should have been involved in your view and why? i. Why do you think they were not involved? ii. What in your view would have been the impact on the policy if they had been involved? i. What factors enabled different sectors to work together in implementing these promoting physical activity policies j. What were the challenges encountered in implementing the promoting physical activity policies? (Probe for challenges in bringing several sectors together to support implementation) 6. What were the benefits of involving many actors in the policy processes? i. What losses were incurred from involving many actors? 7. What would you recommend to facilitate the working of different sectors in formulating / implementing promoting physical activity policies for the future? Probe for recommendations to facilitate different sectors in working together in implementing of promoting physical activity programs? 8. What kind of funding is available for implementation of the promoting physical activity policies mentioned? Probe for amount of funding; Sources of funding Probe are there arrangements such as joint budgeting and delegated financing aimed at addressing promoting physical activity issues? Promoting Healthy Diet A. Policy Context My last set of questions is about policies related to promoting healthy diet. 1. What is your opinion on healthy diet policy development in this country? a. Which healthy diet policies are you aware of in this country? b. What was the rationale for formulating the healthy diet policies policy? (probe for each policy mentioned) 2. What issues led to the development of the healthy diet policies?(for each policy mentioned) a. What issues within Nigeria context led to the development of the healthy die policies (Probe for: whether there were political changes, health sector reforms, Organizational changes, fiscal policies, and changes in government b. What issues at Global level influenced the formulation of healthy diet policies (probe for global movements, declarations, meetings) B. Actors in policy formulation 3. To what extent were you involved in the formulation of these healthy diet policies? (Probe for each policy mentioned) Analysis of Non-communicable Diseases Prevention Policies in Nigeria

94 i. What was your role in the formulation of the healthy diet policy ii. Please describe your experience in participating in the formulation of the policy (What in your opinion went well? What could have been done differently?) 4. Which other sectors were involved in the formulation of the policies a. Who led the process in formulating the healthy diet policies b. What was the role of the sectors that were involved? (Probe for the sectors mentioned) c. Who else should have been involved in your view and why? iii. Why do you think they were not involved? iv. What in your view would have been the impact on the policy if they had been involved? d. What strategies were used to bring the different stakeholders/sectors to work together in formulating these healthy diet policies? e. What were the challenges encountered in involving the different sectors in formulating the healthy diet policies? C. Policy implementation 5. To what extent have the healthy diet policies been implemented (probe for each policy mentioned?) k. How were you involved in the implementation of the healthy diet policies? l. Which other sectors/ stakeholders were involved in the implementation? m. Who else should have been involved in your view and why? i. Why do you think they were not involved? ii. What in your view would have been the impact on the policy if they had been involved? n. What factors enabled different sectors to work together in implementing these healthy diet policies o. What were the challenges encountered in implementing the healthy diet policies(probe for challenges in bringing several sectors together to support implementation) 6. What were the benefits of involving many actors in the policy processes? a. What losses were incurred from involving many actors? 7. What would you recommend to facilitate the working of different sectors in formulating / implementing healthy diet policies for the future? Probe for recommendations to facilitate different sectors in working together in implementing of healthy diet programs? 8. What kind of funding is available for implementation of the healthy diet policies mentioned? Probe: For amount of funding; Sources of funding) 80 Analysis of Non-communicable Diseases Prevention Policies in Nigeria 2017

95 Probe: Are there arrangements such as joint budgeting and delegated financing aimed at addressing healthy diet issues? Is there anything else significant about the development NCD policy /program in Nigeria that we have not discussed so far? Ask for relevant documents and names of other potential respondents. Thank you for participating in this study. Your responses will be very helpful to our understanding of NCD prevention policies and how to enhance MSA in developing the policies. This is the end of our discussion on today. Analysis of Non-communicable Diseases Prevention Policies in Nigeria

96 Annex 4: Code book CODE NAME EXAMPLES Best buys Tobacco use Harmful alcohol use Unhealthy diet Physical inactivity POLICY CONTEXT Political and historical context Socio-economic factors Health system Technological factors Global movements; declarations; laws influenced by NCD prevention policy development; national-level political changes; health sector reforms; fiscal policies; organizational changes (such as changes in government structure); historical origins of the policy, including what issues it meant to address and how issue identification has evolved over time Any social factors (such as increase in NCDs prevalence); country economic growth; global and local financial situation; conflicting development agendas health sector reform, Technological factors that influenced the development NCD prevention (such as packaging, structures) POLICY CONTENT Specific policies developed: rationale for developing the policy; risk factors addressed by the policy (such as tobacco use, harmful alcohol use, unhealthy diet and physical inactivity). Specific policy objectives: best buy interventions included tax increases, smoke-free indoor workplaces and public places, bans on tobacco and alcohol advertising, promotion and sponsorship, health information and warnings, restricted access to retailed alcohol, reduced salt intake in food Other interventions mentioned: mechanisms for actualizing policy POLICY PROCESS Formulation process The policy implementation process Agenda setting: landmark or critical events at the national level that influenced the policy agenda; key steps; strategies employed to engage other sectors (such as Consultations, meeting workshops, etc); challenges encountered in the process; development of implementation guidelines Extent of implementation of the NCD best buys and how implementation is proceeding incountry (for each policy/best buy ); any gaps in implementation, constraints and enabling factors to process implementation; future plans for implementation of the best buys; coordination mechanisms; M&E 82 Analysis of Non-communicable Diseases Prevention Policies in Nigeria 2017

97 ACTORS Actors Facilitating factors Hindering factors Funding Recommendations The sector that led the process; other sectors involved; role of sectors involved in formulation (such as funding meetings, provision of technical assistance) and implementation; relevant institutions not involved in formulation or implementation; coordination of the sectors (such as composition, roles and responsibilities, resources); actor experiences in policy formulation (such as what went well, and what could have been done differently) and implementation; existence of governance structures for MSA at different levels (such as central government, parliament and civil service), their participation in and experiences with these structures; their interests and concerns with the policy process, how these may have influenced their participation and how these were addressed; benefits of involving different sectors in formulation and implementation process; mechanisms for engagement beyond the government with the general public, civil society and the industry in the formulation of policies, the participation of the different actor and experiences with these mechanisms; challenges of involving many actors in formulation or implementation Formulation; implementation; actor involvement/msa Formulation; implementation; actor involvement/msa Funding available for implementation of each policy; sources of funding; amounts; funding arrangements such as joint budgeting and delegated financing aimed at addressing NCD prevention issues; involvement of the different actors in setting these mechanisms up and their participation in such mechanisms; funders interests Recommendations and suggestions on how to make multi-sectorality better in future, mechanisms and structures through which multi-sectoral can be enhanced Other issues emerging from the interviews Key issues that consistently emerge from interviews with the key informants regarding NCDs prevention and control policies. Key informants might be constantly referring to NCD issues not directly addressed by the interview guide and we need to draw this out if the issues relate to multi-sectoral action. Analysis of Non-communicable Diseases Prevention Policies in Nigeria

98 Annex 5: Ethical Approval Certificate 84 Analysis of Non-communicable Diseases Prevention Policies in Nigeria 2017