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Asia & the Pacific Policy Studies, vol. 2, no. 2, pp. 293–309 doi: 10.1002/app5.84

Special Research Article on Health Policy How Can We Strengthen Governance of Non-communicable Diseases in Pacific Island Countries and Territories? Roger S. Magnusson and David Patterson*

Abstract

1. Introduction

Pacific island countries and territories (PICTs) are some of the most geographically isolated in the world. Most have small populations and economies. In addition to the economic challenges that they face because of isolation and size are the risks of climate disaster and the challenge of noncommunicable diseases (NCDs), including cardiovascular disease, cancer, diabetes and tobacco-related diseases. This article builds on knowledge about the key features that characterise effective national responses to NCDs, as embodied in the World Health Organization’s Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013–2020. It seeks to identify some promising strategies for strengthening the governance and law reform processes that will be required to enhance the capacity of small island states to reduce NCD risks in their populations.

Pacific island countries and territories (PICTs) are some of the most geographically isolated in the world. With a total population of around 9.8 million, some PICTs have very high population densities (Table 1). With the obvious exceptions of Papua New Guinea (PNG) and Fiji, most are small, lack economies of scale and are heavily dependent on imports. In September 2011, Pacific Island Forum leaders declared that non-communicable diseases (NCDs) had become a ‘human, social and economic crisis’ (Pacific Islands Forum Secretariat 2011, Annex 2). The United Nations General Assembly has also recognised NCDs as ‘one of the major challenges for small island developing states (SIDS) in the twenty-first century’ (United Nations General Assembly (UNGA) 2014, p. 19). The leading NCDs that impact on health systems include heart disease and stroke, cancer, diabetes and chronic respiratory diseases (WHO 2014a). These are driven by a cluster of inter-related risk factors including tobacco use, harmful use of alcohol, poor diet (excess intake of saturated fat, salt and sugar), obesity and lack of physical activity (WHO 2014a). This article considers how strengthened governance at national and regional levels might assist PICTs to make progress in implementing the regulatory and legal reforms that are needed to reduce risk factors and disease outcomes across PICTs. The challenge that NCDs pose for PICTs will be relevant to

Key words: public health, regulation, non-communicable disease, Pacific islands, law

* Magnusson: Sydney Law School, University of Sydney, Sydney, New South Wales 2006, Australia; Patterson: Department of Strategy and Innovation, International Development Law Organisation (IDLO), Rome, Italy. Corresponding author: Magnusson, email ⬍Roger.magnusson@sydney .edu.au⬎.

© 2015 The Authors. Asia and the Pacific Policy Studies published by Crawford School of Public Policy at The Australian National University and Wiley Publishing Asia Pty Ltd. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

55,000 10,000 54,000 18,000

21 sq km island 14 islands covering 457 sq km 340 islands covering 458 sq km; 8 are inhabited

6 64 98 138 420 86

284 64 74

40

499 122

299

323 134

147

16 22 22

47 14

Population density (persons/km2)b

Sources: (a) Statistics sourced from country summaries, as linked from Australian Government, Department of Foreign Affairs and Trade (n.d.) Pacific Islands, viewed December 2014 ⬍http://www.dfat.gov.au/geo/pacific/⬎. (b) Statistics sourced from Statistics for Development (2013) 2013 Population and Demographic Indicators (January 2014 Update), viewed December 2014 ⬍http://www.spc.int/sdd/⬎.

1500 195,000 1,400 103,000 11,000 12,000

55,000 12,000 277,300

160,000 107,000

Island of 540 sq km 32 atolls in 3 main groups covering 811 sq km, extending 4,000 km across the equator (3.5 million sq km of ocean) 5 islands and 29 atolls covering 181 sq km

5 islands; 2 atolls covering 199 sq km 15 islands; 237 sq km land over 2 million sq km ocean 5 archipelagos covering 3,521 sq km spread across 5.3 million sq km 295 sq km island Four inhabited, 5 uninhabited islands covering 2.934 sq km 3 coral atolls of 12 sq km 36 inhabited islands; 3 island groups covering 749 sq km 9 coral atolls of 26 sq km spread across 1.3 million sq km 2 island groups lying 160 km apart, covering 142 sq km

106,000

7,059,653 555,000 266,000

858,000 258,000

Approximate resident population (2013)a

607 islands; 65 inhabited covering 701 sq km

800 islands covering 18,376 sq km Grande Terre, Loyalty Islands, Belep archipelago covering 18,576 sq km PNG mainland and 600 islands covering 462,840 sq km 1,000 islands; 9 island groups spread over 28,000 sq km 83 islands covering 12,281 sq km extending over 1,000 km

Geographya,b

Asia & the Pacific Policy Studies

Niue (self-governing country in free association with New Zealand) Samoa Tokelau (self-governing territory of New Zealand) Tonga Tuvalu Wallis and Fortuna (French overseas territory)

Republic of the Marshall Islands (independent country in compact of Free Association with the United States) Nauru Commonwealth of the Northern Mariana Islands (US self-governing territory) Palau (independent country in compact of Free Association with the United States) Polynesia American Samoa (US self-governing territory) Cook Islands French Polynesia (French overseas territory)

Papua New Guinea Solomon Islands Vanuatu Micronesia Federated States of Micronesia (independent country in compact of Free Association with the United States) Guam (US self-governing territory) Republic of Kiribati

Melanesia Fiji New Caledonia (French overseas territory)

Region and country/territory

Table 1 Geographic and Demographic Features of Pacific Island Countries and Territories

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© 2015 The Authors. Asia and the Pacific Policy Studies published by Crawford School of Public Policy at The Australian National University and Wiley Publishing Asia Pty Ltd

Magnusson and Patterson: Governance of NCDs in Pacific Islands all SIDS, which comprise over one quarter of the countries in the world (UN Sustainable Development Knowledge Platform n.d.a).

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Table 2 Selected Non-communicable Diseases Risk Factors in Pacific Island Countries and Territories, Compared with Australia Obesity rates % (2013)c

2. Evidence Supporting the Need for Action on NCDs in the Pacific Although developed and developing countries both share a rising burden from NCDs, the underlying risk factors driving the epidemic are higher in many PICTs, and this means that future rates of disease will also be higher, imposing heavy costs on fragile health systems (Table 2) (Anderson 2013). For example, obesity rates in some PICTs have almost reached 60 per cent. Four of seven countries with female obesity rates exceeding 50 per cent are PICTs: Kiribati, the Federated States of Micronesia, Tonga and Samoa (Ng et al. 2014). Combined rates of overweight and obesity among men and women in some PICTs nearly reach or exceed 80 per cent: Tonga (86 per cent), Samoa (84 per cent) and Kiribati (79 per cent) (Ng et al. 2014). Obesity and poor diet are driving worldleading rates of diabetes across the region. In Tokelau, the Federated States of Micronesia and Marshall Islands, more than one third of the population is affected by diabetes (Table 2) (Chan et al. 2014). Kiribati and the Cook Islands are not far behind. According to World Bank indicators, Kiribati, PNG, the Solomon Islands and Tonga have some of the highest smoking rates in the world (World Bank n.d.). NCDs account for around 70 per cent of deaths in PICTs, and in some cases, the rate is higher. Importantly, many of these NCD-related deaths are premature (before age 60 years) and are preventable (World Bank 2014, p. 7). NCDs are a development challenge in PICTs because they threaten gains in life expectancy and impose heavy financial burdens on governments because of rising health care costs (Anderson 2013). For example, dialysis in Samoa costs US$38,686 per year (Anderson 2013). Expensive, ongoing health care costs like these are unsustainable for small island economies, yet these costs can only rise further in future because of the ageing of the population and the pipeline

Country

Men >20 years

Women >20 years

Men and women >20 years

Kiribati Samoa Tonga Australia

39 46 52 28

56 69 67 30

47.5 57.5 59.5 29

Smoking prevalence % (2011)d,e Country Kiribati Papua New Guinea Solomon Islands Tonga Australiaa

Men >15 years

Women >15 years

Men and women >20 years

67 55

37 27

52 41

45

18

32

43 18

12 14

28 16

Diabetes prevalence % (2013)f,g Country

Total adult population

Cook Islands Federated State of Micronesia French Polynesia Kiribati Marshall Islands Nauru Tokelau Vanuatu Australiab

26 35 22 29 35 23 38 24 4

Notes: (a) Australian data are for daily smoking rates among adults aged ⬎18 years, for 2011–2012. (b) Australian data are for the period 2011–2012. Sources: (c) Statistics sourced from Ng et al. (2014). (d) Statistics sourced from World Bank (n.d.). (e) Statistics for Australia sourced from Australian Bureau of Statistics (ABS) (2012) Australia’s Health Survey: First Results, 2011–2012, Tobacco Smoking. 4364.0.55.001, 29 October 2012, viewed December 2014 ⬍http://www.abs.gov.au/ ausstats/[email protected]/Lookup/73963BA1EA6D6221CA257 AA30014BE3E?opendocument⬎. (f) Statistics sourced from Chan et al. (2014). (g) Statistics for Australia sourced from ABS (2012) Australia’s Health Survey: First Results, 2011–2012, Diabetes Mellitus. 4364. 0.55. 001, 29 October 2012, viewed December 2014 ⬍http://www.abs .gov.au/ausstats/[email protected]/Lookup/D4F2A67B76B06C12 CA257AA30014BC65?opendocument⬎.


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effects of current high rates of risk factors, particularly smoking and obesity (Anderson 2013). Countries with small populations need to preserve their precious human resources. NCDs affect people during their productive years, interrupting paid employment, imposing care demands that prevent other family members from working, and further weakening household finances. In the Pacific, health expenditure is primarily financed by the government—with assistance from development partners. Evidence from Samoa, Tonga and Vanuatu suggests that expenditure on health in PICTs is already substantial as a share of total government expenditure, placing constraints on further growth in the absence of revenue-generating policies, such as higher taxes on tobacco, alcohol and sugary drinks (Anderson 2013). In many countries, NCD risk factors reflect socio-economic disparities, with poorer communities at greater risk. In the Pacific, however, the relationship between socioeconomic variables, NCD risk factors and disease is complex and evolving. For example, in Fiji, male and female urban dwellers and those with a tertiary education are less likely to be smokers; on the other hand, urban dwellers are less likely to eat the recommended amount of fruit and vegetables, although a tertiary education increased the odds of doing so for both men and women. Men with higher levels of education are more likely to be obese, although the opposite is true for women (WPRO 2010). Educated men are also more likely to have diabetes, whereas living in an urban area increases the likelihood of having diabetes for both men and women (WPRO 2010). 3. Priority Interventions for NCD Prevention and Control An important goal for PICTs, in making progress on the prevention and control of NCDs, is to implement the World Health Organization (WHO)’s Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013–2020 (‘WHO global action plan’)

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(WHO 2013a). The action plan sets out a range of cost-effective priorities (‘best buys’) covering tobacco use, harmful use of alcohol, improving diet and physical activity (Table 3). One notable feature of these evidence-based, cost-effective interventions is that they can be expected to alter patterns of consumption and lifestyle risks across the population, without the need to engage directly and specifically with each individual. By contrast, individually focused lifestyle interventions that seek to support or encourage individuals to choose a healthier lifestyle are likely to be very costineffective, yielding only trivial benefits to population health (Cobiac et al. 2012). In 2013, the World Health Assembly approved a global monitoring framework that built on the previously agreed global target of a 25 per cent relative reduction in mortality from cardiovascular diseases, cancer, diabetes and chronic respiratory diseases—by 2025 (WHO 2012). The framework consists of 8 additional voluntary targets for reducing risk factors and improving the response of national health systems, and 25 indicators for measuring progress towards each target (WHO 2013b). These voluntary targets include a 10 per cent relative reduction in the harmful use of alcohol; a 10 per cent relative reduction in the prevalence of insufficient physical activity; a 30 per cent reduction in mean population salt intake; a 30 per cent relative reduction in prevalence of current tobacco use; and a halt in the rise of diabetes and obesity. The WHO’s ‘best buys’ for preventing and controlling NCDs are included in both the WHO Western Pacific Regional Action Plan on NCDs (WPRO 2014), and the NCD Roadmap Report funded by the World Bank (2014). The Roadmap Report was prepared at the request of Pacific Forum Economic Ministers in 2013 and includes a summary of recommendations for a wide range of relevant ministries (Annex 6). Another feature is the ‘country roadmap’: a set of actions that specified ministries are recommended to take each year for the period 2014–2017 (Annex 10). At the Joint Forum Economic and Pacific Health Ministers Meeting in Honiara in July 2014, Economic and Health Ministers from


Magnusson and Patterson: Governance of NCDs in Pacific Islands

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Table 3 Selected Legal and Regulatory Priorities for Reducing Risk Factors for Non-communicable Diseasesa,b (Best Buy = ✓) Tobacco

Alcohol

Diet, and physical activity

Other strategies

Comprehensive implementation of the WHO Framework Convention on Tobacco Control, especially: • Reducing the affordability of tobacco products by increasing tobacco excise taxes (FCTC Article 6) ✓ • Banning smoking in public places, including workplaces, public transport, bars and restaurants (FCTC Article 8) ✓ • Health warnings on tobacco products, and at point of sale; labelling controls (FCTC Article 11,12) ✓ • Comprehensive bans on tobacco advertising, promotion and sponsorship, including in all media, in community settings, and in retail establishments (FCTC Article 13) ✓ • Bans on sales of tobacco to and by children, with monitoring and enforcement (FCTC Article 16) • Penalties for smuggled and counterfeit tobacco; with adequate resources for monitoring and enforcement (Article 15; protocol to eliminate illicit trade in tobacco products) • Affordable treatment for tobacco dependence: supporting interventions for smoking cessation in primary care; affordable pharmacological therapies (FCTC Article 14) Implementation of the WHO Global Alcohol Strategy, especially: • Increasing excise taxes on alcoholic beverages ✓ • Penalties for smuggled and informal alcohol, with adequate resources for monitoring and enforcement • Restrictions on alcohol advertising and promotion through the media, in community settings and retail establishments; restrictions on alcohol sponsorship of cultural and sporting events ✓ • Controls on access to retailed alcohol, including minimum age purchasing laws, licensing and other controls on hours of retail sale, location and density of retail outlets ✓ • Health warnings on alcohol products and at point of sale • Drink-driving counter-measures, including random breath testing, a maximum of 0.5 g/l blood alcohol concentration (BAC) limit for adult drivers, with a reduced or zero limit for younger drivers Building on the WHO Global Strategy on Diet, Physical Activity and Health: • Institutional and governance reform to enable development of a comprehensive and multi-sectoral approach to policy development for diet, nutrition and physical activity, with input from key sectors (agriculture, transport, education, environmental and urban planning, sport, youth, industry, finance, and media and communications). City and local governments should have a legal mandate to play a leading role • Review agricultural policies to ensure they contribute to a healthy and sustainable food supply • Encourage or require food reformulation in order to reduce levels of salt (✓), saturated fat and added sugar • Require food manufacturers to replace trans fats with polyunsaturated fats ✓ • Place restriction on the marketing of foods and beverages high in salt, sugar and fats (especially to children): WHO, set of recommendations on marketing of foods and non-alcoholic beverages to children WHA 64.14, adopted May 2010) • Improve food labelling to encourage healthier choices • Fiscal measures such as reduced taxation on healthier foods, and/or higher taxation for foods to be consumed in lower quantities • Legislation to protect women’s right to breast-feed, without harassment or discrimination Hepatitis B vaccination

Sources: (a) WHO (2013a). (b) Alwan A (2011) Global Status Report on Noncommunicable Diseases 2010. WHO, Geneva, pp. 3–4, 47–60. FCTC, Framework Convention on Tobacco Control; WHA, World Health Authority; WHO, World Health Organization.


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Pacific Island Forum countries agreed that NCDs are ‘financially unsustainable’ and committed to develop country-specific roadmaps covering the following five priorities (Joint Economic Forum and Pacific Health Ministers Meeting 2014). These are: — Strengthening tobacco control; — Considering an increase in taxation of alcohol products; — Reducing consumption of unhealthy food and drink; — Improving efficiency of existing health expenditure; and — Strengthening the evidence base to ensure optimal use of resources. In addition, ministers have committed to choosing additional interventions from the NCD roadmap best suited to each country’s circumstances. In 2013, the United Nations Economic and Social Council (ECOSOC) established a United Nations Task Force on NCDs, co-chaired by WHO, to coordinate the activities of United Nations (UN) organisations and inter-governmental organisations in implementing the WHO global action plan, including the voluntary targets. Building on this model, a regional, UN Pacific Interagency Task Force on NCD Prevention and Control (UN PIATF) has been established to coordinate UN agencies working with Pacific island countries on NCD prevention and control (UN Sustainable Development Knowledge Platform n.d.b). At the global level, the WHO has established a separate global coordination mechanism to facilitate engagement between member states, UN agencies, other relevant inter-governmental agencies and non-state actors (WHO n.d.a). The aim of the coordination mechanism is to enhance collaboration across sectors at national, regional and global levels, while safeguarding the WHO and public health processes from the potential for conflicts of interest (World Health Assembly 2014). This global structure also has a regional counterpart in the Pacific NCD Partnership, which is intended to facilitate collaboration between Pacific Health Ministers, WHO and

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UN agencies, regional organisations (the Pacific Islands Forum, the Secretariat of the Pacific Community, the Pacific Island Health Officers Association), the NCD Alliance, World Bank and development partners (aid programmes of Australia, New Zealand and the United States) (UN Sustainable Development Knowledge Platform n.d.c). In summary, global and regional architecture to support the implementation of policies to prevent and control NCDs is coming into place (Tuitama et al. 2014). But what of the interventions themselves? 4. What Makes Change Happen? The Challenge of Implementation Despite the excellent set of policy options contained in the NCD Roadmap Report, the fact remains that PICTs are constrained by their lack of resources, including physical infrastructure, health workforce and sustainable financing. Small countries cannot do everything. The WHO’s ‘best buys’ and the Roadmap priorities may be cost-effective, but this does not mean that implementing them creates cost savings. On the contrary, implementation inevitably costs money, and where health budgets are severely limited, governments may be forced to choose between treating people who are sick, and seeking to reduce the future burden of NCDs and associated expenditures. It is not surprising that the political imperative to direct limited resources towards those who are currently sick often wins out. For this reason, there is a strong case for governments to seek to expand their revenue base at the same time as they scale up their budget for NCD control, particularly by increasing taxes on those products that most contribute to NCDs, including tobacco, alcohol, and unhealthy foods and sugarsweetened beverages (World Bank 2014: 11–14, 93–94). Despite this, raising taxes may be politically challenging for governments: ‘the [political] pain in raising taxes is now, [whereas] the public health gain is later’ (World Bank 2014: 11–12). Whether seeking to raise taxes, or to implement the other regulatory responses


Magnusson and Patterson: Governance of NCDs in Pacific Islands included in Table 3, governments will also face resistance from tobacco, alcohol and processed food industries and potentially from other countries, including development partners (Thow et al. 2010; Moodie et al. 2013; Snowdon & Thow 2013). For all these reasons, the challenge PICTs face is not the lack of knowledge about the policies that could make a difference, but implementation: translating knowledge into actions at the country level (Figure 1). This leads to some profound questions, including: — What makes change happen? — What makes governments do things? — What are the catalysts for leadership and better governance? — How can the roadmaps agreed to by Pacific economic and health ministers be operationalised within countries in the region? It is surprising how little attention the challenge of implementation has received in public health literature, despite it being one of the most important constraints on progress globally (Wibulpolprasert et al. 2011). Beaglehole et al. (2011) pointed out the need for political leadership by politicians and ‘issue champions’, as well as leadership structures to facilitate an inter-sectoral Figure 1 A Simple Model for Analysing Policy Action

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approach that preserves the status of NCDs as a priority for all relevant sectors of government. They emphasised the importance of strengthening health systems, focusing on primary care, the need for international cooperation, supported by accountability and monitoring systems to measure progress (Beaglehole et al. 2011). These requirements are not in dispute, but how can they best be achieved in PICTs?

5. Implementation and Governance The focus of this article is regulation and governance: strengthening the capacity of countries to implement the law and governance reforms that will be needed in order to deliver on the commitments made by economic and health ministers under the NCD roadmap process (Joint Economic Forum and Pacific Health Ministers Meeting 2014). A common understanding of governance is that it refers to the capacity of governments to develop and implement policies and programmes (World Bank 1994). The law plays an important role in health sector governance, through legislation, regulations, executive orders, fiscal policies (for example raising taxes), as well as through institutional architecture, and administrative and political processes. In many cases, the law’s contribution to NCD control takes the form of statutory prescriptions, such as a prohibition on smoking in indoor public places, a higher excise rate on alcohol or a ban on sales of sugary drinks within 2 km of all schools (Pacific Islands Forum Secretariat 2014). In other cases, law plays a facilitative role. For example, Tonga’s Health Promotion Foundation Act (2007) creates a new institution with a mandate to engage in a range of health promotion and policy activities. Despite the central role of government in the prevention and control of NCDs, ‘health governance’ is not only achieved by and through government, but in collaboration with other actors outside of government whose goals are aligned with public health.


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6. Planning for Implementation The need for national leadership in addressing NCDs is well recognised, but what does this mean in practical terms in PICTs? ‘Issue champions’ may help focus media interest or place issues on government agendas, yet the role that leadership plays in implementation necessarily goes beyond the personal efforts of leaders. Leadership needs to be embedded within political and administrative structures that preserve the status of NCDs as a priority for all relevant sectors of government. Institutionalising and formalising mechanisms are vital in order to ensure that NCDs do not fall off the political agenda, and to ensure that progress continues, even when the energy of issue champions wears thin. Leadership requires a plan. Bonita et al. (2013) have advocated a simple, step-wise approach in implementing priority interventions for NCDs that is well suited to PICTs. Step 1 involves planning and mobilising. This includes: — Estimating the burden of risk factors and the extent of unmet need for NCD preventive and treatment services; — Using national leadership to build a national, multi-sectoral mechanism with a legal or political mandate for driving policy change across a number of sectors; — Strengthening political commitment and accountability by promoting the engagement of civil society; — Creating a national action plan; and — Building the human resources, financial resources, and the legal and regulatory capacity needed to implement policies and to engage in governance reforms. With these building blocks in place, step 2 involves implementing a very limited sub-set of priority interventions, and expanding to implement others as resources permit. This limited set of policy measures covers tobacco control, reducing dietary salt and multi-drug treatment for those who have had a heart attack or stroke or who are identified within

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the primary health system as being at high risk. Step 3 of the model involves monitoring and assessment, and making plans to accelerate progress based on evidence of impact. Holding national leaders accountable for their actions, at the regional level, will be crucial to making progress on NCDs in PICTs. When accountability mechanisms work well, they may even encourage a virtuous cycle as PICTs compete to implement best practice.

7. Potential Opportunities for Strengthening Governance in PICTs The country NCD roadmap approach adopted by Joint Forum Economic and Pacific Health Ministers is the most promising regional strategy for implementing the WHO’s costeffective priorities for NCD prevention and control. Countries developing country-specific roadmaps, and adopting a stepwise approach to the implementation of policy priorities, as suggested by Bonita and colleagues, may also find it helpful to consider the principles and approaches identified in the WHO global action plan. The WHO (2013a) has recommended that countries: — Take a human rights approach that strives for universal access to priority health services; — Take an equity-based approach that seeks to reverse disparities in health; — Recognise the central role of government; — Take multi-sectoral action; — Adopt interventions through all stage of the life course; — Empower individuals and communities; — Keep the focus on evidence-based strategies; and — Manage any conflicts of interest. In the remainder of this article, we draw selectively from this list of attributes and consider how they might be put into operation by PICTs in order to strengthen governance arrangements for NCDs at national and regional levels.


Magnusson and Patterson: Governance of NCDs in Pacific Islands 7.1 NCDs and the Right to Health Although urgent action on NCDs makes good economic sense for PICTs, the challenge of NCDs is more than just about responding to rising health expenditures, or the impoverishing impact of out-of-pocket payments on families. The obligation of governments to take action on NCDs is grounded in the right to health. All countries have ratified at least one international treaty that imposes obligations on government regarding the right to health (WHO 2014a, 2014b). All members of the Pacific Islands Forum as well as Fiji (currently suspended from the Forum) are members of the WHO, whose objective is ‘the attainment by all peoples of the highest possible level of health’ (WHO 1948, article 1). In order to discharge their obligations under the right to health, countries must strengthen the components of their health systems, including health information systems, health financing, human resources, infrastructure and the provision of essential medicines and technology (WHO 2007). Addressing NCDs and their risk factors is also an essential requirement for making progress on universal health coverage (UHC), which has been described as ‘all people receiving quality health services that meet their needs without exposing them to financial hardship in paying for them’ (WHO 2013c, p. 3). The definition of UHC encompasses both health services for individuals, and nonpersonal, prevention-oriented public policies implemented outside the health sector in order to respond to the determinants of health (WHO 2014b). In addition to the right to health, countries that have signed and ratified the Framework Convention on Tobacco Control (FCTC) have legal obligations under international law to implement its requirements within their national legal systems (WHO 2005). Grounding the response to NCDs in international human rights law focuses attention on the equality and the collective entitlements of all members of the population. Framing NCDs in the Pacific as an issue of health justice is important in order to engage the commitment of civil society organisations, both in PICTs

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themselves, and in those countries that provide development assistance to PICTs. People who live in PICTs should not be obliged to accept shorter lives and lower standards of health because they live in a small country, a poor country or because they are isolated. Human rights law provides the normative language to contest the injustices of history, geography and small economies of scale, and to provide hope for the future. Right to health concepts provide a language for conceptualising the obligations of government, despite the significant changes in trade, agriculture, diet, work and lifestyle that have altered the burden of disease in the Pacific (Cassels 2006). Without a solid appreciation of their health sovereignty, and the right to health of all members of the population, PICTs risk being viewed by multinational businesses as dumping grounds for cheap, unhealthy food, or as flourishing markets for alcohol and tobacco (Thow et al. 2010; Stuckler et al. 2012). The right to health provides a principled basis for regulation that applies to both imported and domestically produced tobacco, alcohol and processed food products. For example, Chand et al. (2011) measured the trans-fatty acid content of 64 snacks and fast food products in Fiji, all but seven of which were domestically produced. A total of 60 products were found to contain ⬎2 per cent trans fat per 100 g/fat, and 3 samples contained ⬎20 per cent trans fat (pizza averaged 19 per cent, and bakery products 16 per cent trans fat per 100 g/fat, respectively) (Chand et al. 2011). The WHO has identified the elimination and replacement of trans fats with unsaturated fats as a cost-effective priority for reducing cardiovascular diseases, diabetes and other conditions associated with trans fat intake (WHO 2011, 52–53, 2013a). National bans on industrially produced, partially hydrogenated vegetable oils in food are the most effective strategy and are an appropriate strategy when there is a clear case for eliminating a harmful substance from the food supply (Downs et al. 2013). PICTs ought not to accept health risks that their larger trading and development partners are unwilling to accept. In the United States,


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for example, the Food and Drug Administration is revising the current classification of partially hydrogenated oils as ‘generally recognized as safe’ under the Federal Food, Drug, and Cosmetics Act (Tavernise 2013; US FDA 2013). In the Pacific, a ban would likely require a regional approach, but the point is that the language of human rights is well suited to challenging complacency and drawing attention—in the language of the International Covenant on Economic, Social and Cultural Rights—to the right of everyone to the ‘enjoyment of the highest attainable standard of physical and mental health’ (United Nations [UN] 1976, article 12[1]).

7.2 Inter-sectoral Action on NCDs No concept gets more emphasis in the literature on NCDs than inter-sectoral action. The WHO global action plan recognises that many of the determinants of NCDs, as well as many of the policies that are needed to respond effectively, lie outside the health sector and within the operational control of other ministries (WHO 2013a). Embedded in this point is the fact that many things will need to be done across many sectors if governments are to successfully reduce high rates of NCDs and risk factors. An all-sectors approach is also necessary if NCDs are to achieve the level of political support that is needed to ensure sustainable funding and to pass implementing legislation (Table 4). The country NCD roadmap approach approved at the Joint Economic Forum and Health Ministers Meeting provides a solid foundation for progress. It sets out next steps for which identified national Ministries are accountable, with a commitment to report back in 2015 on progress achieved (Joint Forum

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Economic and Pacific Health Ministers Meeting 2014). But what happens when the ministers go home to their own countries? How can countries embed inter-sectoral action within the process of government? A number of countries, including Mexico (Acuerdo por el que se crea el Consejo Nacional para la Prevención y Control de las Enfermedades Crónicas No Transmisibles [Agreement Establishing the National Council for the Prevention and Control of Chronic Diseases] 2010) and the United States (Patient Protection and Affordable Care Act of 2009; US Department of Health and Human Services n.d.) have formalised an inter-sectoral approach by creating a national council for the prevention of NCDs that brings together the heads of national agencies. Other strategies include cross-ministerial executive committees, task forces, action teams and jointly shared strategies that set out intergovernmental goals (Bonita et al. 2013). The contribution these processes can make include mediating tensions between the interests of different ministries and holding each ministry accountable for the actions it needs to take to contribute meaningfully to agreed national targets (Bonita et al. 2013). In addition to formalising a crosssectoral approach at the national level, inter-sectoral collaboration needs to occur at the regional level. For example, the DirectorGeneral of the Secretariat of the Pacific Community (SPC), Colin Tukuitonga, has requested that each of SPC’s seven thematic divisions make a concrete contribution to two of SPC’s flagship, inter-sectoral programmes, on climate change and NCDs (Tukuitonga C 2014, unpublished data). As a simple example, the fisheries division will now need to consider how matters within its responsibility might contribute to NCD

Table 4 An ‘All Sectors’ Approach to Non-communicable Disease Prevention and Control Prime Minister’s Office Ministry of Customs and Excise

Attorney General Ministry of Education

Ministries of Labour and Industry National Statistics Office Civil Society

Ministry of Sport Ministry of Transport Regional Organisations

Ministry of Agriculture Ministries of Finance and Economic Planning Ministry of Trade Development Partners —

Ministry of Communications Ministry of Health Police Private Sector —


Magnusson and Patterson: Governance of NCDs in Pacific Islands prevention; for example, by encouraging domestic consumption of fish. In July 2014, Joint Forum Economic and Pacific Health Ministers agreed to establish a high-level, multi-sectoral mechanism to coordinate and drive NCD work in PICTs (Joint Forum Economic and Pacific Health Ministers Meeting 2014). This represents a potentially important piece of new regional architecture, especially if it involves heads of health and provides a voice for civil society. PICTs could extend this further by adopting regional goals supported by the national targets that would be necessary to achieve them. The Apia Communiqué, made at the Tenth Pacific Health Ministers meeting in July 2013, adopted the goal of a tobacco-free Pacific by 2025, with adult prevalence of tobacco below 5 per cent in each country (WPRO et al. 2013). This is a good start, but should be underwritten by a set of interim and full-term targets that build on the state of progress in each country, and by goals and targets for other priority risk factors. Targets and goals are not, of course, sufficient by themselves. Progress in tobacco control requires an adequately resourced tobacco control unit within the Ministry of Health. Establishing regulatory functions within the health ministry, in turn, requires human resources, infrastructure, sustainable budgeting to pay salaries and framework legislation that gives public health officers the legal powers they need to perform their functions effectively. 7.3 Partnerships and Collaboration The WHO global action plan recognises that successful action on NCDs requires actions to be taken by a broad number of stakeholders (WHO 2013a). This includes faith-based organisations; human rights and labour organisations; organisations focused on children, adolescents and people living with disabilities; and ‘women as change-agents in families and communities’ (WHO 2013a, p. 24). The participation of grass roots organisations can ‘empower society and improve the accountability of public

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health policies, legislation and services’ (WHO 2013a, p. 22; Wibulpolprasert et al. 2011). In its 2008 World Health Report, the WHO (2008, p. 25) pointed out that: As with other entitlements that are now taken for granted in almost all high-income countries, universal health coverage has generally been struggled for and won by social movements, not spontaneously bestowed by political leaders.

NCDs are likely to be no different. Progress is likely to be something that is ‘struggled for and won by social movements’, and in the absence of vibrant social movements, there may be little to hold governments accountable for their commitments (Swinburn et al. 2015). The participation of civil society is integral to progress on NCDs, because representative groups will be more sensitive to the shortcomings of services, to the absence of effective policies and to problems with political commitment and financing. Non-government organisations also play a crucial role in ‘increasing the visibility of health inequities’ (WHO 2008, p. 34). Although the UN PIATF and the Pacific NCD Partnership have been established, mirroring coordination structures at the global level, there is yet no regional counterpart to the NCD Alliance—a coalition of civil society voices focused on improving NCD outcomes in the Pacific. A Pacific NCD alliance with a strong human rights focus could provide a powerful voice for those affected by NCDs in the region, holding governments accountable for their actions in implementing country roadmaps, lobbying regional organisations and development funders, and highlighting the huge impact of loss of traditional diets, import dependency and the growth of trade in harmful products across the region. Such a regional coalition should include representation from community-based health promotion groups, organisations of people affected by NCDs, faith-based organisations, organisations advocating for the rights of women and children, and health professionals—the Healthy Caribbean Coalition provides a good model (Healthy Caribbean Coalition n.d.).


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The international and regional experience with human immunodeficiency virus (HIV) holds many lessons for the challenge of preventing and controlling NCDs in the Pacific. NCDs, like HIV, are caused by human behaviours that are modifiable, yet largely determined by cultural, social and economic factors. In both cases, prevention benefits from the testimony and advocacy of persons who are affected. Access to medicines is an issue for both people living with HIV and for people affected by NCDs. Discrimination is an issue for both groups, particularly for persons with diabetes (Hannan 2009). Considering gender in policies to address prevention and treatment is also a challenge for both HIV and NCDs. The various ways that NCDs impact on women and girls, whether as patients or carers, reflect the challenges of HIV and AIDS. For the reasons given above, governments in PICTs are more likely to honour their commitments under the NCD roadmap if they partner with civil society groups in policy development, health promotion and advocacy. This may require a change of thinking within ministries—which may be wary of patient support groups and other advocacy organisations that may be critical of government. In many PICTs, there is a natural synergy—yet to be tapped—between faithbased organisations, including the Christian churches, and NCD prevention. Countries need to find innovative ways of encouraging partnerships with faith-based organisations, but without delegating government responsibility for action in a way that would frame lifestyle risk factors as purely a matter of individual responsibility. 7.4 The Power of Regional Action Responding effectively to NCDs requires not only inter-sectoral collaboration and partnerships with civil society, but collective action across PICTs at the regional level. NCDs are a regional challenge for many of the same reasons they are a global challenge (Magnusson 2010). First, as the NCD roadmap process illustrates, regional action can be a catalyst for setting goals, securing govern-

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ments’ commitment to act, monitoring progress and holding countries accountable for their actions. Second, regional cooperation can help to overcome the ‘isolation of dispersed communities’ (WHO 2008, p. 30) by enabling the sharing of country experiences and knowledge about what laws, policies and approaches are working on the ground. Third, regional leadership and collaboration can assist PICTs to compensate for limited resources at the national level. Although individual PICTs may be unable to afford the additional infrastructure, technologies and human resources that they each need, a regional approach to expanding resources may be both manageable and cost-effective (WHO 2008). For example, a small PICT might think twice about recruiting new staff to work in tobacco, alcohol or diabetes control. However, by sharing a new appointment, and credentialing a public health professional to work across several jurisdictions, two or three smaller PICTs may be able to scale up their capacity in a financially sustainable way. Getting the working relationships that might provide the catalyst for this level of cooperation will likely require regular meetings not only between ministers, but also between senior department heads. The WHO has recommended that countries also consider mobile resources to overcome distance and geographical difficulties, using communications technologies (WHO 2008). Where these experiments in regional collaboration work well, they should be considered more broadly by other PICTs. Fourth, a regional approach is vital when it comes to assisting PICTs to navigate their responsibilities under global and regional trade and investment agreements (WHO n.d.b; Gleeson & Friel 2013; Thow & McGrady 2014; Voon et al. 2014). For example, although World Trade Organisation (WTO) agreements impose obligations on WTO members under international law, the complaints mechanism enables these agreements to function as weapons in the political economy of global trade, giving them a political and economic impact that extends beyond their legal significance. Defending a WTO complaint is likely to create significant


Magnusson and Patterson: Governance of NCDs in Pacific Islands hardship for a small Pacific island country, and the threat of such complaints may prevent PICTs from acting boldly to address the enormous health challenges they face. In 2007, Samoa banned the importation or domestic distribution of fatty turkey tails, but was forced to reverse the ban as a condition of WTO membership (WTO 2011). In 2013, Tonga introduced an excise tax of 50¢/litre for sugar-sweetened beverages (‘SSBs’), and $1/kg for a range of animal fats, in order to discourage consumption of fatty meat, including mutton flaps and turkey tails (Excise Tax [Amendment] Order [2013 Tonga]; WTO 2014, pp. 6, 28, 35). Fiscal policies are a crucial strategy if PICTs are to reduce the dietary risk factors for NCDs (Snowdon & Thow 2013; World Bank 2014). Yet, such policies are controversial in Australia, New Zealand and the United States, which, in addition to being development partners to Pacific island countries, are also sources of the cheap fatty products that play a role in entrenching NCDs in PICTs. Regional coordination is likely to be the most effective way of assisting Pacific island countries to design regulatory policies that meet health objectives, while responding to political pressure from trading (and development) partners and avoiding trade disputes. 7.5 Taking a Life-Course Approach The WHO points out that the opportunities for the prevention and control of NCDs occur at multiple stages of life and that ‘interventions in early life often offer the best chance for primary prevention’ (WHO 2013a, p. 12). Programmes and policies supporting maternal and child health provide the opportunity to address NCD risk factors, including through support for breastfeeding, improving perinatal nutrition, preventing childhood obesity, preventing smoking initiation and children’s oral health. Preventive dental health, in particular, is an under-used frame for conceptualising and justifying policies for healthy eating and the prevention of obesity and diabetes. Evidence suggests a dose–response relationship between

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dietary sugars and dental caries and that limiting sugar to ⬍5 per cent of energy intake is necessary in order to minimise the burden of dental caries throughout life (Moynihan & Kelly 2014; Sheiham & James 2014). In addition, there is evidence that consumption of sugar-sweetened beverages has contributed to population weight gain and rising rates of diabetes (Malik et al. 2010a, 2010b; Woodward-Lopez et al. 2011). Policies to support dental health in children include improving infrastructure (water fluoridation, where feasible), eliminating the sale of SSBs and confectionary in schools, limiting access to SSBs in proximity to schools (as suggested by the NCD Roadmap Report) (World Bank 2014) and taxing SSBs (Escobar et al. 2013; World Bank 2014; Beaglehole 2014). Clever framing of policies addressing NCD risks is a practical necessity, given the relative lack of attention by development partners to public policies for the prevention of obesity and diabetes, and to the fiscal and regulatory policies that will be needed to moderate the future growth of NCD mortality in PICTs. 8. Summary This article has focused on the role of governance and regulation in implementing priority interventions for NCDs. The constraints on addressing NCDs in the Pacific lie with implementation, rather than the absence of evidence for action, or lack of knowledge about effective policies. The principles that underpin the WHO global action plan provide a useful set of concepts to assist countries in strengthening their national roadmaps for NCDs. In summary: — Right to health: Governments have legal responsibilities to take concrete steps to strengthen the components of their health systems and to implement policies outside of the health sector that address key health risks, including tobacco use, harmful use of alcohol, poor diet and obesity. The right to health provides civil society organisations with powerful legal concepts and language for challenging the


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assumption that small, isolated, importdependent countries should be dumping grounds for harmful products. National and regional capacity building on NCDs, law and human rights is needed, including in governments, national and regional academic institutions, and civil society organisations. Inter-sectoral approach: Economic and Health Ministers from Pacific Island Forum countries have committed their countries to adopting the NCD country roadmap approach. Implementing this approach will require formal structures to embed inter-sectoral cooperation between relevant ministries. Partnerships and participation: Civil society organisations can play an important role in the prevention and control of NCDs, particularly by increasing accountability for the implementation of priority policies, supporting effective enforcement of legislation and provision of services. The absence of a unified, regional voice for civil society organisations, including faithbased organisations, is an important missing piece in the regional response to NCDs. Regional action: Regional organisations are already providing the catalyst for commitments by Pacific island countries to take action on NCDs. A collective, regional approach could assist PICTs in setting goals and targets, monitoring progress, sharing evidence and experience, developing shared human resources, and adopting a regional approach to trade and health issues. Life-course approach: NCDs need to be addressed throughout the life-course. This approach, in turn, provides opportunities for framing action on NCDs in ways that enlist the support and understanding of local communities, and trading and development partners. For example, there are a number of interventions to reduce childhood obesity that could be usefully framed and implemented as elements of strategies for maternal and child nutrition, and dental health, respectively.

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April 2015. The authors gratefully acknowledge the editorial assistance of Dr Belinda Reeve and Ms Jan Muhunthan.

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