The role of principled engagement in public health policymaking: the case of Zambia’s prolonged efforts to develop a comprehensive tobacco control policy

Figures & data

Figure 1. Emerson’s integrative framework for collaborative governance [19].

Table 1. Study participants.

Sector	Number of Interviews
Civil Society	4
Ministry of Local Government	2
Ministry of Labour	1
Ministry of Health	5
Ministry of Agriculture	4
Ministry of Commerce	2
Ministry of Education	2
Ministry of Finance	3
World Health Organisation	2
Ministry of Justice	2
Total Interviews	27

Table 2. Major themes and sub-themes of the general systems context and factors shaping principled engagement in the tobacco policy process.

Major theme	Sub-themes
General systems context affecting collaborative engagement
Unfavourable legal context	Conflicting intra-sector tobacco laws and policies Lack of enforcement of the tobacco-free laws
Adverse socioeconomic context	Tobacco contributes to national economy Tobacco industry interference in some sectors
Thematic areas relating to the elements of principled engagement
Poor planning of meetings and frequent changes in tobacco focal point persons	Irregular meetings and prolonged consultation Frequent changes in tobacco focal point persons
Lack of active and meaningful participation	Local government feel they are assigned a passive role Some sectors take less leadership on tobacco control within their organisations Sectors assigning junior staff to attend meetings
Communication challenges among the key stakeholders	Non-functional communication channels Limited communication among sectors outside the consultative meetings Communication hampered by the view that public health conflicts with social-sector goals Flexibility and open mindedness vital to enhancing communication Need to build appropriate communication mechanisms

Table A1. Document review of tobacco laws and policies in Zambia.

Laws	Objective of the law	Position on collaboration in tobacco consumption control
1. Public Health Act, No. 12 of 1930 (as amended to Act No. 22 of 1995)	The Act provides for the notification, prevention and suppression of infectious diseases, regulates all matters concerned with public health including water, food supplies sanitation and housing.	Does not clearly state the role of collaboration in tobacco consumption control efforts, focuses more on infectious diseases control and general matters of public health
2. Tobacco Act No. 64 Chap. 237	The Act provides for the promotion, control and regulation of production, marketing and packing, control of export and import of tobacco, the direction and promotion of research in connection with tobacco.	Not concerned with tobacco consumption control, but rather the main focus is on marketing and production.
3. Tobacco Mktg & Licensing Rules – subsidiary of the tobacco Act	Provide rules for licensing of graders, buyers, auction floors, marking of bales for sale, packaging of tobacco for sale, and sale of tobacco by auction	No clearly stated position on collaboration regarding tobacco consumption control
4. Statutory Instrument 138 of 1968-tobacco general regulations	Regulates permits to export tobacco, prescription of noxious substances, prohibition against sale of tobacco treated with certain substances, fumigation and certificate of inspection.	No clearly stated position on collaboration regarding tobacco consumption control
5. Statutory Instrument 139 of 1968. Act No. 13 of 1994 – Registration of growers	Regulates registration of growers, registration periods, duration of registration, application for registration	No clearly stated position on collaboration regarding tobacco consumption control
6. Statutory Instrument 140 of 1968. Act No. 68 of 1977 – regulations for prescribed classes of tobacco	Regulates the prescribed classes of tobacco	No clearly stated position on collaboration regarding tobacco consumption control
7. Statutory Instrument 163 of 1992-public health tobacco regulations	Regulation concerned with labelling, prohibition of commercial advertising on billboards and newspapers, reference to health in advertising, sale of tobacco to children, prohibition of smoking in places.	Targets regulation of tobacco promotion and consumption but provides no clearly stated guidelines on the role of collaboration
8. Statutory Instrument 185 of 2008. Th local government Act No. 281 – prohibition of smoking in public places regulations	Prohibits smoking in public places	Targets regulation of tobacco promotion and consumption but provides no clearly stated guidelines on the role of collaboration

Table A2. Document review of tobacco-related policies.

Policies	Objective of the policy	Position on collaboration in tobacco consumption control
1. 7th National Development Plan 2017–2021	To create a diversified and resilient economy for sustained growth and socioeconomic transformation driven, among others, by agriculture, tourism, manufacturing and mining.	Departs from sectoral-based planning to an integrated multisectoral development approach, but there no mention of this with regards to tobacco consumption control
2. National Cancer Control Strategic Plan 2016–2021	This strategic plan provides guidance on the interventions needed to reduce the burden of cancers in Zambia.	Recognises the role of other sectors in controlling tobacco consumption, a key risk factor for cancers in Zambia
3. National Health in all Policies Strategic Framework _2017–21	To ensure that all sectors include health and well-being as key considerations in policy development. lays a strong foundation for the implementation of the strategies	Proposes that health is integrated in other sector policies; i.e. education, gender, water and sanitation and environmental protection, community development, social services and local government. No specific mention of tobacco
4. Zambia National Health Research Priorities_2018–2021	To align the production of research evidence to the National Health Goals and Objectives as well as provide guidance to researchers, research institutions, academic institutions, policy makers, program implementers, health development partners and other partners on Zambia’s health research focus.	Does no clearly recognise tobacco as a key priority research area among all the key themes of focus. Collaboration is key area of implementing the prescribed policy areas.
5. Zambia National NCD Strategic Plan 2013–216	To raise priority accorded to the prevention and control of NCDs in the national agenda through advocacy and multi-sectoral partnership	Recognises tobacco as a major risk factor for non-communicable diseases and proposes strategic direction to address. However, collaboration in implementing tobacco consumption control policy is not emphasised.
6. Zambia National Health Strategic Plan 2017–2021	To improve the health status of people in Zambia in order to contribute to increased productivity and socio-economic development	Not clear on strategies to address tobacco consumption in Zambia
7. Vision 2030	Zambia to become a prosperous Middle-Income Nation by 2030	Not clear on strategies to address tobacco consumption in Zambia

Table

	Main question	Probe
	Please tell me about yourself?	Your job You experience What is your current role with regards to tobacco control?
	I would like to find out the role of governance in intersectoral action to control tobacco in Zambia?	Collaboration Describe your understanding of collaboration Describe your understanding of intersectoral action and its role in addressing tobacco control? What are some of the collaborative/intersectoral activities that you are involved in order to address tobacco control? Is there any prior history of collaboration to act on tobacco? what was the activity? who and how was it initiated? Probe for any efforts to involve other sectors in tobacco policy development. What was their role? How should the various sectors be engaged in intersectoral action against tobacco? What sorts of incentives and motivations to encourage intersectoral action across sectors? How would describe the roles and participation of various sector stakeholders in intersectoral action on tobacco? Describe some of the factors that may facilitate intersectoral collaboration to address tobacco in Zambia? Explain the factors that may hinder intersectoral collaboration to address tobacco in Zambia? Probe for political and social cultural Probe regulatory –policy and law What would you consider to be the most important factors for collaboration on tobacco control to occur? Do you have suggestions of how intersectoral collaboration may be enhanced?Strategic vision How supportive is the policy and legal environment for intersectoral action on tobacco in Zambia? Describe some of the challenges you have encountered in coming up with a comprehensive tobacco policy? How can they be addressed?Leadership and coordination What do you understand by coordination? Please explain how intersectoral coordination is conducted in tobacco control in Zambia? If not, how should it be? What role does leadership play in fostering intersectoral action? What form of leadership is most appropriate for tobacco control in the Zambian context? What kind of coordination activities are in place/needed to address tobacco control? What structures are in place to coordinate intersectoral action on tobacco? How effective do you think are those structures? What process are in place to govern and follow up on intersectoral action on tobacco control? Describe some of the factors that may facilitate the coordination of intersectoral action on tobacco control in Zambia? Explain the factors that may hinder efforts coordination action on tobacco control across sectors? Probe for political and social cultural Probe for regulatory – Policy and law Do you have any suggestion of how coordination of action to reduce tobacco across sectors can be enhanced?
End of Interview

Table

Main question	Probe
● Please tell me about yourself?	Your job You experience What is your current role with regards to tobacco control?
● I would like to find out the role of governance in intersectoral action to control tobacco in Zambia?	Collaboration Describe your understanding of collaboration Describe your understanding of intersectoral action and its role in addressing tobacco control? What are some of the collaborative/intersectoral activities that you are involved in order to address tobacco control? Is there any prior history of collaboration to act on tobacco with other sectors – MoH? what was the activity? who and how was it initiated? Probe for any efforts to involve other sectors in tobacco policy development. How should the various sectors be engaged in intersectoral action against tobacco? What sorts of incentives and motivations to encourage multisectoral action across sectors? How would describe the roles and participation of various sector stakeholders in intersectoral action on tobacco? Do you have any activities within your sector addressing tobacco – probe incorporation into policy or program Describe some of the factors that/may facilitate intersectoral collaboration to address tobacco in Zambia? Explain the factors that/may hinder intersectoral collaboration to address tobacco in Zambia? Probe for political and social cultural Probe regulatory –policy and law What would you consider to be the most important factors for collaboration and action on tobacco control to occur? Do you have suggestions of how collaboration may be enhanced?Strategic vision How supportive is the policy and legal environment for intersectoral action on tobacco in Zambia? Describe some of the challenges you have encountered in coming up with a comprehensive tobacco policy? How can they be addressed?
	Leadership and coordination What sought of intersectoral action is/should be prioritised for your sector to reduce tobacco? What are some of the capacities required for your sector to be able to implement this action? What role does leadership play in fostering intersectoral action? What form of leadership is most appropriate for tobacco control in your sector? What do you understand by coordination? Please explain how intersectoral coordination is conducted in tobacco control in Zambia? If not, how should it be? What are some of coordination activities to address tobacco control? What structure is in place to coordinate intersectoral action on tobacco? How effective is the structures and mechanisms? Are there any policies in place to facilitate the coordination intersectoral coordination? What process are in place to govern and follow up on intersectoral action on tobacco control? Describe some of the factors that/may facilitate the coordination of intersectoral action on tobacco control in Zambia? Explain the factors that/may hinder efforts coordination action on tobacco control across sectors? Probe for political and social cultural Probe for regulatory – Policy and law Do you have any suggestion of how coordination of action to reduce tobacco across sectors can be enhanced?
End of Interview

Ruckert A, Labonté R, Lencucha R, Goma F, Drope J. Exploring the political economy nexus of tobacco production and control: a case study from Zambia. Criti Public Health. 2022;33:1–12.

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