Policy-makers’ perspectives on implementation of cross-sectoral nutrition policies, Western Pacific Region

Abstract Implementation of effective cross-sectoral nutrition policies remains a challenge worldwide. By reviewing reports from World Health Organization meetings and consultations – convened for policy-makers representing Member States of the Western Pacific Region – we provide an insight into how national policy-makers and external actors can support different dimensions of nutrition policy implementation. Key insights of policy-makers attending food and nutrition-centred meetings include that country-level implementation of nutrition policy relies on strong policy design, organizational planning and governance mechanisms that promote collective responsibility across multiple sectors. Policy-makers responsible for implementing nutrition policies face major challenges resulting from limited capacity, both within and external to government, particularly in relation to monitoring and enforcement activities. Successful implementation of nutrition policy measures will require greater political will to provide the requisite resources and institutional structures to ensure sustained policy effectiveness. Nongovernmental partners, including international agencies and researchers, have an opportunity to support policy implementation by providing technical support to Member States to frame action on nutrition in a more compelling way. They can also help policy-makers to build the organizational and structural capacity to coordinate cross-sectoral policy. Improved policy design, planning and governance and strategic capacity-building, supported by external partners, can strengthen the sustained implementation of cross-sectoral nutrition policy and improve nutrition outcomes.


Introduction
Since 2015, undernourishment as well as the prevalence of overweight and obesity have increased in many countries. 1 The burden of malnutrition is a global health priority and Member States of the United Nations (UN) have committed to act during the Global Decade of Action on Nutrition (2016-2025). 2 Dietary risk factors play a significant role in the development of noncommunicable diseases, 3 which caused 41 million of the 55 million global deaths in 2019. 4 Dietary factors are also a key determinant of malnutrition and nutrient deficiencies. Hence, improving population diets could avert one in five deaths globally. 5 More recently, diet-related noncommunicable diseases have been associated with coronavirus disease 2019 (COVID-19) severity. 6 The World Health Organization (WHO) has identified strategies for improving diets and health, 7,8 and 77% (128) of the 167 WHO Member States surveyed for the Global Nutrition Policy Review (2016-2017) had comprehensive nutrition policies in place to address all forms of malnutrition. 9 However, the implementation of specific globally recommended policies for addressing diet-related noncommunicable diseases has been uneven. 10 Policy advocates have faced persistent challenges in developing measures to promote healthy food environments. These challenges include strong opposition from the food industry, pressures to design policies that minimize impacts on trade [11][12][13] and lack of data to convincingly demonstrate the link between particular policies and health outcomes. 14 Additionally, hard-earned political attention towards diet-related noncommunicable disease prevention may now be displaced by the global response to COVID-19. 15,16 Evidence suggests that implementing food and nutrition policy measures adopted by governments is a persistent challenge. 17,18 In particular, high reliance on non-health sectors, including education, trade, finance and commerce, to implement many globally recommended nutrition policies has been identified as a common impediment to successful implementation. 19 Most countries (135/169 surveyed) have adopted governance mechanisms that oversee the implementation of cross-sectoral nutrition policies, 20 but evidence suggests that these mechanisms often are ineffective at fostering the uptake of nutrition actions across those sectors. 19,21 While many influences on policy implementation are specific to the local context, the common challenges underlying these factors, including poor political commitment to nutrition and limited human and financial capacity, suggest there is an opportunity for regional and other cross-country learning. 22,23 However, evidence is limited regarding ways to facilitate effective policy implementation. 24,25 Records for policy insights WHO regularly convenes regional meetings and consultations with Member State representatives to discuss and consult on key policy challenges facing countries, to assess country progress, and to facilitate cross-regional communication on the implementation of effective policy measures. Food and nutrition policy-makers working at national and regional levels have a collective experience on factors that promote or inhibit the scaling up and sustained implementation of cross-sectoral nutrition policies. Their perspectives and experiences are representative of their communities of practice 26 and their learned experience can inform practice-based strategies. 27 Hence, reports from these meetings can be used to assess policy-makers' insights and lessons learnt from the implementation of cross-sectoral nutrition policy measures.
Policy & practice Implementation of nutrition policies Erica Reeve et al.
To identify strategies that can sustain the implementation of crosssectoral food and nutrition policies, we drew information from the meeting reports of all food or nutrition-centred meetings and consultations hosted by the WHO Regional Office for the Western Pacific. In the Western Pacific Region, noncommunicable diseases cause an estimated 80% of all deaths, 28,29 underscoring the need for preventive policy action. Member States in the region have collectively taken action to adopt WHO-recommended food and nutrition policy measures 9,29,30 and, thus, policy-makers have a wealth of experience navigating nutrition policy implementation. 13,[31][32][33] We retrieved meeting reports from WHO's Institutional Repository for Information Sharing 34 for meetings held between the launch of the Global Strategy on Diet, Physical Activity and Health in 2004 and the end of 2020. We included biregional or subregional meeting reports, drawing on text reported as participant presentations, groupwork or panel discussions led by Member State representatives. One author extracted all data from the included reports while a second author, who has a background in policy implementation, verified all extractions. We analysed the content of the meeting reports using a deductive coding framework based on well established theories of policy implementation and capacity needs (Fig. 1). 35,36 The coding framework included codes related to: (i) the policy process (that is, policy context, process, content and actors); 35 (ii) institutional structures and policy implementation; [37][38][39] and (iii) systemic capacity needs, particularly in relation to organizational systems (e.g. structures, systems, supervision, role clarity, decentralized power, planning systems). 36 Between 2004 and 2020, WHO Regional Office for the Western Pacific hosted 29 food and nutrition-centred meetings, consultations and workshops (Table 1). From 2012, we observed a shift from meetings focused on single nutritional risks (e.g. anaemia, salt) towards solution-oriented meetings, directed at noncommunicable disease prevention. Of the meetings, eight related to food safety, seven were related to restrictions on food and beverage marketing and the others largely related to nutrition in early childhood, nutrition surveillance or policy tools that support planning and implementation.

Dimensions of policy implementation
Through the meeting records, we found that contributions by policy-makers at meetings largely centred on four dimensions of policy implementation: (i) the implementation of specific WHO-recommended policy measures to promote improved nutrition; (ii) systems for monitoring and learning from implementation; (iii) the coordination of institutional and governance structures that facilitate engagement of multisectoral government actors; and (iv) the implementation of mechanisms to manage engagement with external stakeholders in nutrition policy ( Table 2). Examples of contributions are given in the data repository. 40

Implementing policy measures
The need for improved or strengthened implementation of policy measures was discussed at 27 meetings. Policymakers identified a range of challenges to implementing specific nutrition policy measures recommended by WHO, which often related to difficulties in communicating and collaborating with implementing stakeholders and the lack of support from decisionmakers in actioning the necessary policy measures. For example, policy-makers often reported being unable to access the requisite funds or personnel to promote and enforce policy activities on an ongoing basis. Policy-makers also frequently mentioned that unclear policy content could undermine a strong and effective policy response. For instance, nutrition regulations commonly lacked clear definitions and ways to classify the healthiness of food or they did not identify mechanisms for enforcement, such as sanctions.
Meeting participants clearly articulated the systemic capacities they would need to better implement nutrition policies in their countries. For instance, policy-makers wanted clearer operational plans for implementing specific policies that identify roles and responsibilities of implementing stakeholders, and clearer oversight and supervision from senior leadership. They identified greater policy coherence as a strategy for overcoming capacity limitations. For example, they  called for changes to food regulations to ensure food labelling mandates contain requisite information to support a strong policy response and the integration of nutrition activities into the operational plans and responsibilities of a broader number of stakeholders. Policy-makers also called for nutrition policies to be underpinned by clear definitions to enable straightforward interpretation and implementation, and strong and clear sanctions to enable effective enforcement. Policy-makers identified the need for a more consistent, compelling and contextually relevant body of evidence demonstrating policy effectiveness to convince governments to commit the requisite resourcing towards nutrition policy implementation and provide appropriate oversight. They also expressed the need for coherent evidence to inform decisions around specific policy parameters (Box 1): for example, consistency in definitions of healthy and unhealthy foods and ages of children to be targeted by restrictions on food marketing.

Monitoring and learning
Opportunities to strengthen the implementation of systems for monitoring and learning were discussed at 21 meetings. Policy-makers indicated they were not confident in systems for monitor-ing and reporting in their countries, in particular noting that data were not being reported back in a way that would necessarily incite reorientation or strengthening of policy measures. They reported lacking the capacity and tools for data collection and reporting, especially where other ministries and stakeholders were involved.
The ability to demonstrate the impact of successful measures was identified as a key determinant for maintaining accountability and garnering political and cross-sectoral support. In the context of capacity constraints, policy-makers identified the critical need for more efficient and reliable mechanisms to collect and collate routine information on policy implementation and compliance (Table 2). Additionally, policy-makers called for monitoring efforts to be extended beyond epidemiological indicators to include contextual influences on policy process and implementation effectiveness.
Meeting participants also noted that policy lessons should be presented such that they are easily interpreted and acted on by those with the power to influence political or public opinion (e.g. experts, media, civil society advocacy groups and community leaders). In order to more powerfully convey relevant nutrition policy messages, policy-makers were seeking skills in knowledge translation.

Multisectoral governance structures
In the reports, there was substantial policy-maker dialogue on mechanisms to strengthen multisectoral coordination and cooperation (17 out of 29 meetings). While most countries had interagency coordination mechanisms to facilitate multisectoral action, these were not necessarily facilitating meaningful dialogue or action. Of primary concern for policy-makers was the perceived lack of priority for nutrition among non-health actors within government, and associated difficulties mobilizing and sustaining input from them over time. Low political will for nutrition measures across government and among political leaders was widely reported at meetings.
Cross-ministerial championship from leaders was deemed critical for eliciting support across sectors (Table 2). In particular, policy-makers believed decision-makers needed to facilitate a Implementation of nutrition policies Erica Reeve et al.
cross-sectoral dialogue that reflects on both problems and solutions. Policymakers from Member States that had achieved some level of policy success attributed that success to the oversight and championship of political leaders. Some of the mechanisms believed to be helpful in inciting and maintaining political interest in nutrition were: the availability of accurate, compelling and (where possible) nuanced data demonstrating the need for the particular policy approach; clear demonstration of both cost-effectiveness and the investment required to achieve policy effectiveness; alignment of policy measures with international accountability systems and commitments; and availability of contextually relevant information demonstrating feasibility and benefits across multiple government sectors.

Managing external stakeholders
Engagement with influential external stakeholders in the nutrition policy space was discussed at 21 of the 29 meetings. External stakeholders most often referred to were regional development partners (including the UN, donors and regional technical support programmes), civil society groups and the food industry.
Policy-makers called for stronger regional and bilateral cooperation to amplify nutrition policy efforts, especially in relation to food regulation, trade and cross-border sales and marketing. Meeting participants considered regional organizations to be in the best position to facilitate functional relationships across countries, for instance, by developing specialist support networks and actively negotiating agreements across common policy challenges. WHO, in particular, was called on to oversee greater policy coherence for nutrition by UN partners working at the country-level and to oversee a research agenda for nutrition policy. Several information gaps and research priorities were identified by policy-makers attending the meetings (Box 1).
Policy-makers frequently referred to the value of a strong and well informed civil society to engage on food and nutrition challenges. However, they noted that civil society groups often lacked the technical capacity and resources for credible and meaningful engagement and they requested that development partners work with these groups to develop the necessary strategic and technical capacities.
Meeting discussions raised numerous examples of where the food industry had undermined or weakened policy implementation efforts, by questioning the mandate of the enforcing agency, by legally opposing or circumnavigating policy rules or by targeting policy implementers (e.g. teachers and nurses). The policy-makers called on academia to enhance their preparedness for diminishing industry influence, for example, by providing evidence to persuasively counter industry objections to globally recommended policies and by developing systems to monitor food industry activity and expose violations of policy measures.

Way forward
Using the findings from our review and with reference to the published literature, we discuss below opportunities to improve policy design, planning, governance and implementation of globally recommended nutrition policies.

Capacity for implementation
Consistent with our theory on capacity, 36 we identified that limitations related to a lack of staffing and resourcing need to be considered during policy development. Capacity challenges could also be partly alleviated through building the systemic capacity of implementing agencies and civil society partners, 36,41,42 that is, the broader strategic and operational capacities required to fully implement a nutrition policy. For instance, skills in planning, implementation and actor mobilization, 41,43 and confidence to generate and interpret monitoring and research for learning and accountability, 41,43 are all likely to be vital for action on nutrition. This approach will require a reorientation of capacity development beyond a focus only on knowledge and technical skills, and towards more strategic competencies including coordination, negotiation, advocacy and leadership. [41][42][43] The findings are also consistent with analyses of national nutrition policies that have found that policies often lack the requisite technical detail and mandate to facilitate a strong and effective policy response. 17,41 Governance and political support Consistent with previous research, the meeting reports confirm that political rhetoric for nutrition is, in many cases, unmatched at the country level by the resources and institutional structures necessary to institute strong policies and to sustain long-term nutrition gains. 22,44,45 Lack of political interest in nutrition is a key reason to why policy implementation is typically insufficiently resourced, and the lack of impact resulting from under-resourcing further compromises commitment. 44,45 Given challenges associated with mobilizing cross-sectoral actors, attracting cross-ministerial oversight of policies affecting population nutrition is needed. Such oversight should facilitate productive dialogue between cross-sectoral leaders and maintain their accountability for addressing nutrition issues. 14,41,45 Implementation of recommended policies for improving nutrition is therefore reliant on garnering the support of policy leaders to engage across all dimensions of policy implementation. To elicit their interest, it will be vital to build the collective capacity of nutrition policy-makers and advocates to act in unison to position nutrition as a matter of importance across several sectors. 46 For example, policy-makers could better position nutrition as an economic and development imperative for action across several public areas, such as human rights and educational outcomes. This framing may be critical in settings where powerful food industry interests undermine and resist increased regulations related to nutrition. 47

External partners
The insights from this review support the operationalization of calls for greater political commitment to improving nutrition. 14,44,45 External partners play an important role in generating political will by lending legitimacy to nutrition issues. 45,46 Regional development partners can strengthen systemic and organizational capacity in countries, 36,41 and can convene bilateral and regional actor networks to amplify collective efforts across countries. 45,47 Furthermore, regional development partners should review their portfolios of support across multiple sectors to ensure that they are promoting coherence with nutrition policies. 48 Our review suggests that WHO meetings can play an important role by engaging policy leaders in dialogue on what is required to sustain effective Policy & practice Implementation of nutrition policies Erica Reeve et al.
implementation beyond policy adoption. WHO already encourages research partners to contribute to evidence-based policy development and facilitates several global accountability mechanisms relevant to nutrition, including the Global nutrition policy reviews. 49 However, WHO has an opportunity to encourage researcher partners to contribute further to the development of reliable and efficient policy monitoring and accountability systems. WHO has established several region-specific nutrient profiling models to strengthen policy implementation, but this analysis of policy-maker perspectives suggests that expanding technical guidance to include further best-practice standards for nutrition policies is needed: for example, sugarsweetened beverage tax design (that is, effective tax rates and taxation mechanisms) and clear definitions for restrictions on marketing to children. A more cohesive approach to bestpractice nutrition policy guidance may be of great practical value for countries, by fostering consistency and efficiency, and strengthening justifications underpinning policy parameters. 50 WHO's Framework Convention for Tobacco Control (FCTC) offers a precedent that could also guide nutrition policy. The comprehensive policy agenda of FCTC requires approval by high-level leaders and whole-of-government action. Furthermore, the FCTC's strong and consistent accountability mechanisms have weakened grounds for opposition by industry. 47

Meeting reports as a data source
The meeting reports we analysed proved useful in capturing aggregated contributions and views of representing officials while overcoming sensitivities commonly associated with interviewing senior policy officials. 51 The findings were consistent with more intensive approaches to data collection (e.g. indepth interviews and review syntheses). 41,42,45 In our case, aggregating the meeting reports represented an efficient mechanism for gathering the perspectives of policy-makers working across a range of diverse policy settings.
However, we acknowledge that the meeting reports represent summaries of proceedings by rapporteurs, rather than a verbatim record of proceedings, and are variable in the level of detail included. As an aggregated source of information, the individual views of policy-makers are rarely made explicit as part of the meeting reports. Further, the contributions of meeting participants are likely to reflect the perspectives of attending individuals and, as such, the diversity of opinions from Member States is not likely to be fully represented. The meeting reports are subject to reporting bias and should be interpreted with caution. However, the breadth of representation from Member States at meetings, and the relevance of the meetings to nutrition policy somewhat countered these limitations. While the meeting reports represent only views from the Western Pacific Region, our comparison with nutrition policy research conducted in other regions 41,42 and globally 44,45 has elucidated that the challenges being reported are similar to those being experienced in other contexts, and the lessons are therefore likely to be applicable to other regions. Nevertheless, the relevance of the findings to other regions requires further examination.

Conclusion
Our review revealed that policy-makers coordinating nutrition policy development and implementation within countries face challenges when implementing such policies, particularly in relation to monitoring and enforcement activities. These challenges result from a lack of human and financial resources across agencies that is required to support implementation. In many settings, governance mechanisms provide inadequate oversight to the commitments and responsibilities health and non-health actors have towards nutrition policies. The lack of commitment to addressing nutrition issues across government likely undermines critical aspects of policy implementation within countries. However, policy-makers have identified key enablers of sustained nutrition policy implementation, and call on political leaders and external partners to support them in progressing towards achieving successful implementation of best-practice food and nutrition policy measures. ■
Policy & practice Implementation of nutrition policies Erica Reeve et al.