Strengthening implementation of diet-related non-communicable disease prevention strategies in Fiji: a qualitative policy landscape analysis

We found the policy landscape in Fiji to be comprehensive and multisectoral (Table 1). There are robust NCD prevention plans within the Ministry of Health’s policy framework however, challenges remain, particularly in relation to the limited attention to multisectoralism in sector plans and the current lack of institutional structure. Although there are a vast number of policy stakeholders involved in the policy process, we noted limited engagement from civil society and the general public. Also, key stakeholder dynamics have been characterised by a dominant influence from industry whose corporate political activity to influence policy has primarily been undertaken by the 12 main food and beverage industry actors in Fiji. There is alignment with WHO recommendations for policy on NCD prevention however these could be strengthened to support the achievement of global targets (Table 2).

Table 1 Policy content for NCD-prevention against WHO Global Action Plan recommendationsTable 2 Documentary policy analysis findings relevant to factors WHO considers in recommendations for NCD preventionMultisectoral policy strengths and opportunities

Fiji has a 20-year (2017 to 2037) National Development Plan (NDP) which is translated into individual sector development plans with comprehensive and inclusive activities to be implemented in five-year blocks. At the heart of the NDP is ‘socioeconomic development for every Fijian,’ aligning with global targets in the Sustainable Development Goals (SDGs) and the Paris Agreement on Climate Change. As of November 2019 there were 11 active policies relevant to diet-related NCD prevention from Economy, Health, Agriculture, Trade, Education and Women and Youth (Table 6 in Appendix 3).

Comparing these policies with the frameworks of Shiffman and Kingdon, we identified three key opportunities for strengthened diet-related NCD prevention relevant to the policy process. These were: (1) the potential for increased multisectoral engagement, governance and institutional structures (2) to include more transparency around budgetary and resource commitments and allocation, and (3) greater commitment to enforcement, monitoring and evaluation mechanisms of current regulatory and fiscal policies (e.g., excise taxes on SSBs).

A multisectoral approach is needed

Multisectoral action was mentioned in almost half of the analysed policies and highlighted by policymakers, who also reported that engagement of non-health sectors was limited. For example:

“.... Having a whole-of-government approach or a whole-of-government policy that cuts across all sectors, that will include the private sector. Major players in the private sector would also include the food industries. It will include civil society organizations, the NGOs and academic institutions, as well. So, everyone has to pitch in to this policy....” Civil Society.

However, some participants explained that non-health sectors often fail to engage in implementing policies related to NCD prevention:

“.... I’m not sure what the others would say, but definitely from my perspective, there’s been limited progress around multisectoral collaboration. The different sectors are still kind of working in isolation....” Development Partner

Poor governance was a barrier to multisectoral action. There was no multisectoral governance or coordinating institutional mechanism overseeing implementation of the national NCD strategy in Fiji:

“.... Well, there should be a formal kind of structure to be able to monitor what is going on in terms of the food and nutrition security. Like, something central so that they are able to say, OK, these people are doing this, this group is doing that, so there is no repetition, and you can allocate resources efficiently...” Government

Transparency in resourcing (commitments and where the money should come from)

Inadequate budgetary and resource allocation was a challenge. Seven policies mentioned budget and resource allocation and of these, only two polices (Draft National Fiji Policy for Food and Nutrition Security and the Fiscal Budget Address) identified defined amounts and sources. Of the remaining five, high-level statements indicating the budget will come from the ‘public health budget’ (Education), ‘partner ministries’ (Health), ‘requests are being made to international donor partners’ (Agriculture) or that the ‘government will allocate resources’ (Trade). Four policies provided no mention of budget or resource allocation and critically, the National NCD Strategy and the NDP did not include budget allocations (the NCD policy had an empty ‘budget’ column in their indicator table). Interview participants, from both inside and outside government, pointed to the lack of sufficient budget allocation as an example of a lack of genuine commitment. For example:

“I think it’s not a priority [NCDs and nutrition]. If you look at the budget, even within the Ministry of Health, you can see that the budget is very low for nutrition....” Development Partner

Monitoring and evaluation of active policies

Shiffman’s priority setting framework highlights the need for monitoring and evaluation to help enforce policy. Participants identified the absence of monitoring and evaluation contributing to a lack of evidence regarding severity of the problem and the (potential) effectiveness of specific policies. However, there were participants who indicated substantial efforts were being made (Table 4). 

“.... I think it’s the monitoring that’s also a big issue in Fiji. We have the policies in place, but actually monitoring them. There definitely needs to be policy around this...” Development Partner

Stakeholder dynamics and the influence of industry

We identified seven groups of stakeholders with an interest in NCD prevention in Fiji. These were (1) government, (2) industry, (3) academia, (4) civil society, (5) development partners, (6) non-government organisations (NGOs), ‘other’ (e.g., faith-based organizations, community), and (7) media. Stakeholder groups had varying levels of interest in the NCD issue which ranged from ‘low’ interest to ‘high’ levels of interest (Table 3). Industry was the only group consistently perceived to have low interest in the NCD issue. Similarly, there was variation across the respective groups as to the level of support they provided for NCD action, ranging from ‘completely supportive’ to ‘competing priorities’.

Table 3 Summary of documentary stakeholder analysisa

Overall, policy documents attributed influence and power to government and development partners because of their extensive provision of funding and technical advice. However, from our 18 stakeholder interviews, no government participants alluded to the power of development partners and only one respondent spoke of development partners being influential or wielding significant power on decision-making:

“.... Sometimes the development banks like the World Bank or the Asian Development Bank. They come with big packages and a commitment for the country, because the country has to repay, and they have their own way of doing things and packaging things and I think they have an influence on how the development agenda prioritizes things....” Development Partner

Participants from government ministries and civil society perceived the food and beverage industry to have the most influence on the policy process and decision-making – as illustrated by the following quote:

“.... Right now, the food industry is the biggest influence. And the big ones, the big names. They come to us [Government] and they understand the situation but change it into their stories. I mean, they are for business...” Government

To achieve a more balanced distribution of power, several interview participants indicated a whole-of-society approach would be most beneficial. Participants perceived government, in the quest of continued support, would be more likely to successfully implement policy actions when communities, civil society, and NGOs are involved in consultations. When asked who should be involved in NCD policy processes, one respondent replied:

“.... I think the key enabler is the community or those stakeholders more at the operational level, rather than at the government level. It is not that government is against it, it is just that it’s lower down in their priority list and I don’t think we should wait for them to pick it up. We can push it up from the operational level or from the stakeholders rather than waiting for big government decisions before we implement....” Civil Society

Corporate political activity and behind-the-scenes influence

We identified 12 businesses/companies manufacturing or selling food and beverages in Fiji. Five were beverage industries, operating under one large corporation (Fiji Beverage Group) and included the transnational corporation of Coca-Cola. Seven were food industries and included two transnational corporations, Nestlé, and the Carpenter Group. Nine were 100% Fiji owned. Of these, four were state interests (Copra Millers, Food Processors, Fiji Sugar Corporation and Fiji Meat Board), and one was a large, private corporation (Punja’s, or FMF).

These Companies positioned themselves on their websites and in the media as making a substantial contribution to the economy of Fiji. Based on data from company and accountancy websites, we estimated that the food and beverage industries collectively employed over 11,600 people in 2018–2019. If the total number of people employed by the Fiji Sugar Corporation are included in this estimate, it increases to a total of 211,600 people or nearly a quarter of Fiji’s population. Fiji Sugar Corporation alone, directly employed 2000, Coca-Cola employed 1100 people (including Paradise Beverages) and Nestlé employed approximately 200 people.

We estimated the Fiji Beverage Group (FBG) generated nearly US$1B for the Fijian economy, Goodman Fielder nearly US$115 M (2017), Punja’s approximately US$87 M (2019) (another source suggested a more modest amount of US$12 M). The two Nestlé factories generated over US$12 m in export sales annually. Furthermore, Nestlé has invested F$20 million in Fiji since it transferred manufacture of an instant noodle line from Nestlé New Zealand to a factory in Ba, north Viti Levu (2018).

Table 4 provides a summary of strategies developed by Mialon et al. [23]. From our corporate political activity analysis, and across the 12 industries identified, we found 11 used the ‘constituency building strategy, nine used the ‘information and messaging’ strategy, and one used the ‘policy substitution’ strategy.’ The FBG used all three strategies, and five industries used two strategies. From our desk-based analysis, we found no examples of the ‘financial incentive,’ legal action’ or the ‘opposition fragmentation and destabilisation’ strategies occurring.

Table 4 Key corporate political activitiesConstituency building

Constituency building was the most widely used strategy (defined in Table 4). Evidence indicated that eleven of the 12 corporations had implemented various initiatives to establish community involvement and support, and to establish relationships with influential actors. The most frequently applied constituency building strategy was marketing, through sponsorship of sports events, buildings, and equipment (four corporations) and cultural activities within the community (three corporations). To illustrate:

“One example is the Coke games, which involves the secondary schools. So, what happened during these games? There’s only distribution of Coke during that game. So instead of water, only Coke or products from Coca Cola is being distributed....” Civil Society

The beverage industry was involved in several initiatives beyond these including supporting gender-related initiatives, environmental recycling programmes, food baskets for the food-insecure and those below the poverty line, and natural disaster relief programmes.

Information and messaging

Information and messaging were the second most common strategy (defined in Table 4). Most messages from both the documentary analysis and stakeholder interviews framed dietary choices as individual choices or responsibility and highlighted the contribution of their products to a ‘wide and varied diet.’

“Sugary drinks are one of the culprits which people love to consume here in this country and around the world. But drinking that in moderation, I believe it would help quite a lot. And I believe that is the case with the food. Also, because there is something like portion control, which Fiji doesn't follow.....” Food Industry

There was evidence of ‘framing’ in some responses to our interviews. For example, one participant deflected attention from their own company by pointing to other products and/or external factors as the ‘culprits’ for NCD burden. Examples were supermarket ‘specials’, the need for education and other lifestyle factors:

“.... Alcoholic beverages are not very good as regards to the NCD concern. People eat a lot of red meat with it and the quantum of red meat which they eat during a drinking session is very substantial. So, alcohol I would say is causing much of the damage, but the red meat consumed with it is causing all that and more damage....” Food Industry

Company websites also indicated the importance of ‘physical activity’ as part of a holistic approach to a healthy lifestyle “for a healthier future and improved quality of life”. Other company websites highlighted the beneficial nutrients in their products (e.g., Fortified flour, coconut oil) or organic, non-genetically modified and gluten free products (e.g., sugar). Some also provided colourful, appealing recipes using their products. One drinks manufacturer claimed they were encouraging responsible marketing to children across the sector and stressed the importance of their presence to the Fijian economy but without citing specific examples.

Two interview participants from industry advocated their adherence to food manufacturing standards and regulations. For example:

“.... We follow all the guidelines from government. We also do the nutritional panel. If we export products to the US and Canada, we follow the FDA guidelines.....” Food Industry

Furthermore, our industry stakeholder participants framed their involvement in the NCD issue - as well as actions taken by other stakeholders - in a proactive and positive manner:

“We have been taking all initiatives [to improving the production process and to export quality products] and the government is quite appreciative of all the things which we do....” Food Industry

Policy substitution

Only the beverage industry (Fiji Beverage Group) had information publicly available for specific actions to invest in healthier products through reformulation and policy substitution (defined in Table 4). However, the companies under the Fiji Beverage Group represented a large proportion of the food and beverage sector and these findings showed their tactics are the most comprehensive in scope.

One local food industry participant indicated their company would be willing to spend money on new products that benefit society if incentivised by the government:

“.... I believe if research is done to find out, for example, if oatmeal really helps to improve their dietary pattern of people. Then, if Fiji doesn't grow oats as such, and they have to be either imported from Australia or Canada or from Europe what would happen?If the duty got to zero, then the oat products become more affordable, yes. Similarly, equipment to manufacture a particular cereal if zero duty is there and we've been told, OK, why don't you install this plant? Why don't you put money behind it? And promote this product, it will really help, really benefit the society. Yes, I believe a company like us would do it....” Food Industry

Opposition fragmentation and destabilisation

We did not find any direct evidence of opposition fragmentation and destabilisation. However, it was perceived by most participants to be a major barrier to NCD policy implementation:

I think industries [have most influence], especially the big industries. They play a strong role in their position. Like, we have experienced this before where there was policy that was going to come out. We would try to do consultations and this industry went around the back, talked with the Minister and that changed everything - it didn’t go through. You know, those are the sort of things that happen. We’ve had two cases like that. The not so big industries tend to follow the formal consultations. It’s the big industries and they have their own way of handling things....” Development Partner

“When we sit in meetings, oh, it’s a beautiful meeting. Until, after that meeting, what happens informally backstage or whatever. That’s when the politics of it comes in. Behind the scenes....” Government.

Several stakeholders (from industry, civil society, government and development partners) indicated that they saw industry involvement in policy design as an ‘enabler’ for addressing NCDs. These participants suggested that although industry was part of the problem, they could also represent a link enabling a long-term solution:

“.... I would suggest getting the industry to come because they would be the enabler....” Civil Society

A stakeholder from the food industry confirmed their support for reducing NCDs in Fiji, but suggested resourcing towards the agents of change was a challenge, generally, within the Pacific region. This resourcing included both from the industry itself but also, from government funding:

“.... I think that whenever we’re [industry] invited to be involved in discussions or workshops, then we are very supportive of it. But ongoing lack of resources can make it a bit difficult to organize, and resourcing appropriately can be really challenging with a lack of funding. It can be difficult to get off the ground compared to more established markets or countries....” Food Industry.

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