The challenges in protecting public health interests in multisectoral governance in the context of small island developing states. The case of tobacco control in Fiji and Vanuatu.

Abstract

Abstract Background The commercial determinants of health (CDoH) drive the rise of NCDs globally, and their regulation requires multisectoral governance. However, the elevation of public health interests can be challenging amidst conflicting policy priorities, particularly in low and middle-income countries (LMICs) where the need for rapid economic development is pronounced. Small island developing states (SIDS) face even more challenges in regulating CDoH, due to their unique socioeconomic, political, and geographic conditions – often called SIDS vulnerabilities – that set them apart from other LMICs. This study aims to explore the institutional conditions that shape health sector actors’ capability to protect public health interests in multisectoral governance, focusing on tobacco control in Fiji and Vanuatu. Methods We employed a qualitative, exploratory case study design. We applied the administrative process theory to inform data collection and analysis. Seventy interviews were completed in Fiji and Vanuatu from 2018 to 2019. Results The findings show that the protection of health interests in tobacco governance is not supported by the institutional conditions in Fiji and Vanuatu. While the policy processes formally ensure a level playing field between actors, policies are often developed through informal mechanisms, and the safeguards to protect public interests from vested private interests are not implemented adequately. SIDS vulnerabilities and weak regulation of political parties contribute to the politicisation of government in both states, resulting in high-level government officials’ questionable “public-interestedness”. The system of checks and balances usually embedded into democratic governments appears to be muted, and policy makers have limited bureaucratic autonomy to elevate health interests in multisectoral policy making amidst high-level government officials’ frequent rotation. Finally, capacity constraints aggravated by SIDS vulnerabilities negatively impact health sector actors' capability to analyse policy alternatives. Conclusions Health sector actors in Fiji and Vanuatu are not supported by institutional conditions that could help them protect public health interests in multisectoral governance, to regulate CDoH originating from the tobacco industry. Institutional conditions in these states are shaped by SIDS vulnerabilities but could be improved by targeted capacity building, governance and political system strengthening.