Table 2 Documentary policy analysis findings relevant to factors WHO considers in recommendations for NCD prevention

Policy content

Multisector policy approach

• All analysed policies acknowledged NCD burden in Fiji. Six policies specifically mentioned multisectoral action was needed for reduced NCD burden, including the overarching National Development Plan (NDP), four from the Ministry of Health and Medical Services (one is in draft form and yet to be endorsed).

Fiscal Policy for NCD prevention

• The NCD Strategic Plan and the Fiscal Budget reports clearly mention fiscal policy as an NCD prevention strategy. The Government of Fiji have in place a range of targeted taxes to reduce the consumption of less healthy products high in sugar, salt and fat.

Production of healthy food

• The NDP indicates that the production of healthy, local food is a priority for Fiji’s food and nutrition security.

• The NCD Strategic Plan mentions ‘backyard’ gardens, and the draft Policy on Food and Nutrition Security provides specific activities and targets to enhance and promote healthy, sustainable, diversified and resilient food systems. The Wellness Policy indicates the influence of the Ministry of Education could enhance gardening activities in the school setting. No other policies mention the production of healthy foods.

Reformulation/food processing

• The NCD Strategic Plan and the draft Policy on Food and Nutrition Security mention reformulation efforts to reduce salt, sugar and fat in locally manufactured products.

School food and guidelines

• The NDP includes a priority to increase interaction and involvement of schools to encourage the younger generation to be more food secure. A current programme includes 84 schools undergoing health promotion awareness. Beyond these strong initiatives for school programmes, four other policies mention school food and canteen guidelines, coming from Ministry of Education and Ministry of Health. The policies from Education have been confirmed to be current, however, there are no timelines or indicators, no review date and no mention of budget/resources or accountability/responsibility.

Marketing

• Two of the 11 policies mentioned marketing regulations (NCD Strategic Plan and the draft Policy on Food and Nutrition Security). Both relate to the adoption and implementation of marketing of non-alcoholic beverages and foods to children as well as enforcing the existing regulations regarding misleading advertising.

Trade

• The Trade Policy briefly mentions diet-related NCDs: ‘In addition to global concerns over health issues surrounding tobacco products, Fiji and other Pacific Islands have concerns over trade in products that are seen as potentially increasing susceptibility to NCDs.’

Framing and beliefs

Nutrition Promotion

• Four of the 11 policies mention health promotion. The overall National Development Plan indicates the importance of food and nutrition security, including measures such as local media campaigns, corporate and civil society to engage in initiatives to encourage consumption of local produce with the promotion of recipes etc., particularly in primary, secondary and tertiary educational settings. The NCD Action Plan has the additional focus of encouraging schools to be safe places for active play.

• Both the draft Policy on Food and Nutrition Security and the Wellness Policy contain comprehensive strategic actions to enhance and increase knowledge and the promotion of healthy diets and lifestyles to reduce NCDS throughout the lifespan.

• All 11 policies analysed alluded to NCDs being a health issue in Fiji. Reasons included NCDs being the leading cause of mortality, morbidity and premature morbidity, the impact on the economy, labour supply and the impact from healthcare costs on government and household budgets.

• From our analysis two sectors (Health and Economy (NDP)) explicitly described causes of NCDs.

• Identified risk factors were biochemical (e.g., blood glucose, lipids), high BMI, an aging population and changing dietary patterns. The draft Policy on Food and Nutrition Security made it clear the food system was the primary driver that led to poor individual consumption choices as well as the high price of local food as a result of reduced food security. Furthermore, the Wellness Policy stated that beyond these underlying drivers, an issue in Fiji is that although wellness is widely promoted for reduced NCDs, it is not understood.

• Five of the six policies outlined those responsible for NCD actions and indicated a multisectoral approach. The sixth (Education) indicated that policy implementation was the responsibility of the school head and canteen operators. The Wellness Policy added the community and individuals also needed to take action and the National Health Strategic Plan indicated there should be health-in-all-policies. The NDP briefly indicated a multisectoral approach was required.

• No policy discussed the role of the state in regulating markets.

• Seven policies gave indication of the most effective policy response for NCDs. The NDP (Economy) gave a general response to suggest ‘reduced premature mortality rates in line with international targets.’ The Ministry of Health’s three policies indicated various responses. For instance, the NCD Strategic Action Plan gave a high-level response of ‘following WHO’s menu of options within the Global NCD Action Plan to achieve the nine targets,’ whereas the National Strategic Health Plan championed the more local ‘Healthy Islands Framework’ as being significant in influencing the current approach to NCDs. This approach utilises a settings approach as well as a ‘Wellness’ concept. The Wellness Policy also adopts this ‘Wellness’ concept but goes an extra step to suggest holistic wellness that incorporates social, spiritual, environmental, occupational, psychological, financial and physical wellbeing. Two policies mentioned multisectoral engagement is essential.

Resources

• Our analysis provided mixed results. Seven policies mentioned budget and resource allocation and of these, only two polices (draft Food and Nutrition Security Policy and the Fiscal Budget Address) gave 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. More importantly, the National NCD Strategy and the NDP gave no mention of budgetary allocation (the NCD policy had an empty ‘budget’ column in their indicator table).

Governance

• Our analysis found all policies suggested NCDs and their prevention strategies should fall under the Ministry of Health and Medical Services. The exception is within the draft Food and Nutrition Security Policy which had a multi-stakeholder, multisectoral, high-level committee to provide a mechanism for reporting implementation activities and outcomes (however, as this is not yet endorsed, there is currently no high-level committee).

Because Trade, Agriculture, Economy and Gender do not address NCDs in their policies, there was no mention of coordination or responses or international commitments to reducing NCD burden and each sector indicated responsibility for their own policy.

Gender & equality

• We found within nutrition-relevant policies, there was an emphasis on the need for equal opportunities in education, social services as well as health. While there was some inclusion across sectors for improving opportunities for women (e.g., In the Trade policy and Agriculture policy), this related largely to improving the economic position of women in Fiji.

Implementation

• The sector specific policies had clear allocation of responsibility to the relevant line ministry, and all line ministries report to the National Development Plan. Two Health and Medical Services policies indicated a multisectoral accountability (draft Food and Nutrition Security Policy and Wellness Policy). Both provided details to suggest accountability was given to the leading sector given responsibility for the action or initiative (e.g., Agriculture for food security targets, Education for school canteen targets, etc.). However, the mechanism for ensuring implementation could have been clearer.

• Nine of the 11 policies included in our analysis provided M&E mechanisms. For instance, the M&E indicators relating to NCDs across the Ministry of Health’s policies were mostly robust and have given clear targets and timelines for evaluative analysis. This included the National Health Strategic Plan, the NCD Strategic Action Plan, the Wellness Policy and the draft Food and Nutrition Security Policy. The latter had a complex multisectoral system for implementation and accountability across sectors and clearly defined each.

• Similarly, the Agricultural Sector Policy Agenda described four stages of the implementation, where evaluation reviews were to be carried out mid-term and mid-2020 for purposes of ‘improving the existing policies to ensure continuity and sustainability.’ No details of how these would be carried out or by whom was included in the policy.