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.

The challenges in protecting public health interests in multisectoral governance in the context of small island developing states. 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The case of tobacco control in Fiji and Vanuatu. Dori Patay, Ashley Schram, Sharon Friel This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2164081/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 28 Apr, 2023 Read the published version in Globalization and Health → Version 1 posted 7 You are reading this latest preprint version 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. small island developing states Pacific commercial determinants of health noncommunicable diseases multisectoral policy multisectoral governance whole-of-government tobacco control Fiji Vanuatu 1. Background The noncommunicable diseases (NCDs) epidemic is a major burden for societies and health systems globally ( 1 ). NCDs not only hinder global efforts to reach the United Nations Sustainable Development Goal (UN SDG) 3 (Good Health and Wellbeing) ( 2 ); they also incur high socioeconomic costs through the disability and loss of productivity resulting from morbidity and premature deaths, which hamper economic development and makes reaching other SDGs even more challenging ( 3 ). Therefore, tackling the drivers of this NCDs epidemic is important not only for health but economic and development purposes. The increased consumption of harmful commodities including tobacco, alcohol and ultra-processed foods drives the global rise of NCDs ( 4 ). The need to regulate the commercial determinants of health (CDoH) – the systems, practices and pathways through which commercial actors increase the availability, affordability, accessibility and demand for harmful commodities ( 5 ) – has been recognised by public health scholars ( 6 , 7 ). However, many countries struggle with both the development and implementation of the necessary multisectoral regulatory policies ( 8 , 9 ). Thus, the capability of health sector actors to protect and elevate public health interests in multisectoral policy making is crucial in governing CDoH. Democratic governments tend to provide multiple opportunities for actors to advance their interests in policy making. This can enable health sector actors to influence non-health sector policies such as trade, industry, agriculture, or economic to optimise their public health impact. However, these processes also provide a chance for commercial actors to formally influence policy makers ( 10 ), where their aim is to ensure a policy and regulatory environment that favours their interests (so-called industry interference) and maximises profits ( 11 ). This has been recognised as a major challenge for public health, as these actors’ profit-oriented interests often conflict with public health interests. Despite whole-of-government mechanisms that should provide an opportunity for health sector actors to elevate health interests in multisectoral governance ( 12 , 13 ), and the recommendations of the Framework Convention on Tobacco Control (FCTC) Article 5.3 on the establishment of terms of engagement to protect public health policy making from tobacco industry interference ( 14 ), health sector actors continue to struggle with protecting public health interests in tobacco governance in many countries ( 15 ). Health sector actors in low- and middle-income countries (LMICs), where economic development is often the primary concern of governments and is led by the narrow interpretation of economic norms ( 6 , 16 , 17 ), are in a particularly difficult situation and often fail to ensure the priority of public health interests over tobacco industry interests ( 15 ). This is a significant issue as LMICs experience 77% of the global mortality from NCDs ( 1 ). Tobacco use itself is predicted to kill 8 million people annually by 2030, and 80% of these deaths will happen in LMICs ( 18 ). Small island developing states (SIDS) are a unique group of LMICs situated in three geographical regions: the Caribbean, the Pacific, and Africa, Indian Ocean, Mediterranean and South China Sea ( 19 ). SIDS have unique socioeconomic, political, and geographic conditions – often called SIDS vulnerabilities – that make their development particularly challenging ( 19 ). These SIDS vulnerabilities, that set them apart from other LMICs, include the small size of their land, population and economies; geographic isolation (from other countries and between islands of the same state); governments that are small in size (fitting to the scale of the population) and with limited human, technical and financial resources; low administrative capacity; infrastructural challenges of travel and supply of goods and services, and their dependence on the policies and conduct of larger economies in their region ( 20 ). Pacific small island developing states (PSIDS) declared an NCD crisis in 2011 ( 21 ). Despite the majority of PSIDS adopting the Tobacco Free Pacific 2025 Goal ( 22 ), the rate of current smokers among males reaches as high as 54–74% in some states – in contrast to the global average of 22% ( 15 , 23 – 26 ). Previous research has shown that PSIDS face challenges in implementing multisectoral NCD prevention policies ( 27 , 28 ), and that their SIDS vulnerabilities potentially aggravate government fragmentation and their susceptibility to tobacco industry influence ( 17 , 29 – 31 ). Understanding the ways institutional conditions – the structures and attributes of governance systems – can support health sector actors to protect health interests against powerful harmful industry interests in possibly the world’s smallest countries is a vital step to tackling the NCD crisis. Yet, the literature on public health policy making in PSIDS provides limited analysis of institutional conditions that affect multisectoral governance ( 30 , 31 ). Particularly, scholarship on tobacco control policy making is PSIDS is scarce ( 30 , 32 ). Therefore, this paper aims to explore the institutional conditions in PSIDS – Fiji and Vanuatu in particular – that shape health sector actors’ capability to protect public health interests in multisectoral tobacco control policy making. This study was conducted as part of a larger research project investigating the ways interests, ideas, and institutions shape multisectoral tobacco governance in Fiji and Vanuatu ( 33 ). 2. Methods We applied a theory-informed, qualitative, exploratory research design in this study. 2.1. Theoretical perspective Data collection and analysis were guided by Croley’s administrative process theory ( 34 ), which arose from new institutionalist scholarship that interprets governance through the operation of institutions ( 35 ). The administrative process theory claims that policy makers can ensure that governance is not dominated by vested interests if five conditions are in place: (i) the policy makers are “public-interested”; (ii) policy making processes ensure a level playing field between actors; (iii) extra-legislative mechanisms, such as judicial reviews and presidential oversight, help maintain policy maker’s autonomy from politics; (iv) policy makers have considerable bureaucratic autonomy (both from politicians and other dominant fractions of the government); and (v) policy makers have the capacity and capability to conduct a careful analysis of policy alternatives ( 34 ). 2.2. Study design, data collection and analysis An exploratory, qualitative case study approach incorporating within-case analysis and cross-case synthesis was applied ( 36 – 38 ). Prior tobacco control and food policy studies successfully employed a similar approach in PSIDS ( 32 , 39 – 42 ). To identify case study countries where health sector actors potentially succeeded in protecting public health interests in tobacco governance, first, we selected PSIDS with recent progress in implementing FCTC measures that regulate the tobacco industry, using WHO MPOWER reports ( 43 ). Then, PSIDS with likely divergent interest in tobacco governance were identified: Fiji was chosen as a country where commercial tobacco farming and manufacturing were detected based on tobacco-related exports ( 44 , 45 ); Vanuatu was selected as a county without an established tobacco industry but with interest in investing in these sectors, through a Google search. The Republic of Fiji has a population of near 900,000, scattered over approx. 110 islands ( 46 ). Since regaining independence from the British Empire in 1970, its politics has been characterised by a series of coups, with the latest in 2009 ( 47 ). In 2014, the democratic government was reinstated ( 47 ). British American Tobacco (BAT) has two processing plants in Fiji, and it has a close relationship with the political elite ( 17 , 48 ). The Republic of Vanuatu counts a population of approx. 410,000 and 65 inhabited islands ( 46 ). From colonisation to 1980, the country was ruled as a joined Anglo-French Condominium ( 46 ). Since then Vanuatu has been characterised by frequently changing governments ( 46 ). Vanuatu has no commercial tobacco farming or manufacturing, but interest in investing in these activities was reported ( 49 ). Data was collected through in-depth interviews between April 2018 and August 2019. A purposive and snowball selection process was applied, targeting participants from government agencies in health, agricultural, trade, industry, finance, and education sectors, civil society organisations; local academic institutions; development partners (intergovernmental and regional organisations, and governmental agencies of donor countries); and the tobacco industry. Most interviews were conducted in person and a few over Skype, with an average duration of 60 minutes. The interview questions were open-ended and semi-structured. The transcription of the interviews was coded against the claims of the administrative process theory constructs in NVivo. The data was triangulated by follow-up interviews and the analysis of relevant parliamentary debates and policy documents. 3. Results Forty-two interviews were conducted in Fiji and 28 in Vanuatu; 21 invitees (including the tobacco industry) declined participation. The number of interviews based on actor type and country is provided in Table 1 . The following presents the results across Croley’s five conditions. Table 1 The distribution of interviews Fiji Vanuatu Type of actor Government agencies 25 21 Civil society organisations & academic institutions 3 1 Development partners 14 6 Policy sector Health 21 10 Trade/Industry 3 5 Agriculture 1 1 Finance/Economy 4 1 Education 2 2 Foreign Affairs 2 1 Multisectoral 9 8 3.1. Low “public health-interestedness” High-level government officials are perceived to have low “public health-interestedness”. Overall, in Fiji and Vanuatu, participants state that government officials at the highest levels are caught up in politics, which often has detrimental effects on their “public health-interestedness” in tobacco control policy making. Others suggest that pursuing short-term economic benefits serve high-level government officials’ political interests more than long-term health benefits. People up the top there do not take [tobacco control] seriously enough. Who is on top? PS [Permanent Secretary] and Minister for Health. (F06, Government) Now it’s only the “technicians” who want to move things, but there is not a real drive from the top. The top is focused on winning the elections and building economic growth. (F28, Development partner) Clientelism and patronage as possible drivers of low “public-interestedness”. Clientelism is the “ proffering of material goods in return for electoral support” ( 50 ), and patronage means the “ exchange of a public sector job for political support” ( 50 ). In Vanuatu, SIDS vulnerabilities, such as the country's small population and land size and geographical layout (i.e., scattered over several islands, which causes infrastructural challenges), the weakness of the government and its developing economy contribute to the limited reach and efficiency of public services. Consequently, communities perceive that they only benefit from politics if their representative gets elected to Parliament. Thus, these vulnerabilities make SIDS particularly conducive to clientelism. Politics is localised. Every small place tries to choose someone from their area in the hope that that person will bring them something or they'll accept some form of bribe to vote to that person again, because it's the only thing they see, they do not get much in services. (V13, Government) Weak political part regulation contributing low “public-interestedness”. Low “public-interestedness” was also seen as being shaped by weak political party regulation contributing to corruption, and frequent political power changes. The regulation of the ways political parties operate – who is allowed to have a political party, how do you create and fund a political party? – is weak in Vanuatu. Consequently, and also fuelled by the geographically fragmented constituency (another SIDS vulnerability), 24 parties were operating in 2014, with this number decreasing to 17 in 2016. To form a majority government, parties need to form coalitions, and high-level government positions are often offered in exchange for support (i.e., patronage). There are many different political parties. […] In Parliament you need to build a majority, so the main group in power will try to build a coalition and they will just buy off the people: “Come I will give you a minister post”. (V11, Development partner) As a result of patronage, important positions in the government might be given to people who are neither skilled nor have the experience for the job. I do not think there's anything that's in the decision-making in the government that is not politicised. Even hiring people, especially jobs that are high-level positions. It's not actually what you can bring to the table, but it's who you know. (V27, Development partner) The Ministers of Health over many years have been all sorts of people who do not have any interest or knowledge. (V13, Civil society) In addition, and due to the limited political system regulation, political power structures frequently shift in Vanuatu: the Prime Minister (PM) was changed seven times between 2008 and 2012 and four times between 2012 and 2016. The PM, between 2016 and 2020, stayed in his role but had to fight off several attempts of impeachment by the Parliament. As political alliances frequently shift in Vanuatu, high-level government offices often change hands; those occupying them are aware of the possibility of short-term duration and, thus, may prioritise personal political interests instead of public interests. One of the issues is that most of them only think about their political interests, parties’ interests, but not national interest. (V11, Development partner) “Public-interestedness” from below. However, there was a phenomenon of “public interestedness” from below, that is, mid-level Ministry of Health (MoH) officials that stayed in one position for a significant length of time tended to be “public-interested”. While the Ministers in Fiji and Vanuatu and the Permanent Secretaries[1] (PSs) in Fiji have often changed several times a year, other lower executive and mid-level officers tend to serve for a longer period. The Department heads in both countries and the Director-General (DG) of MoH in Fiji are held in high regard for being public-interested. The DG has been kind of steering a steady ship at times that has been captured by ministers that do not really understand health in any way. (V15, Government) The progress in tobacco control in both Fiji and Vanuatu were often explained by the personal leadership of these mid-level government officials to sustain MoH efforts despite the challenges posed by the high-level government officials’ low “public-interestedness” The findings around “public-interestedness” show that the clientelism and patronage in both countries – aggravated by SIDS vulnerabilities and weak regulation of the political space – can result in high-level MoH officials in power who are not necessarily motivated by the public but rather personal or political interests. This might be a significant impediment to protecting public health interests when it comes to intersectoral negotiations on multisectoral policies, although “public interestedness” from below (by mid-level government officials) may mitigate this problem. 3.2. Policy making procedures Democratic policy processes should ensure a level playing field and multiple opportunities for actors to influence policy development ( 34 ), and Article 5.3 of FCTC requires the establishment of terms of engagement to protect public health policies from tobacco industry influence ( 14 ). This section presents how the policy making procedures of Fiji and Vanuatu fulfil these requirements. 3.2.1. Policy and legislative process Formally, the policy and legislative process offer several opportunities for intersectoral negotiations in Fiji and Vanuatu. The data reveal at least four opportunities when health sector actors can elevate public health interests: two were identified during policy development and another two in the legislative process. First, during the policy development, consultations must be conducted with the public and relevant actors. The government will never accept anything if it didn’t go through consultations with public, NGOs, government departments, sellers, producers, importers, everybody. (F03, Government) Second, inter-ministerial discussions are to be held in the Cabinet (which in Vanuatu is preceded by an additional lower-level inter-ministerial meeting). If the policy is embedded into legislation, the third opportunity presents itself before the bill is debated in Parliament: a Parliamentary Standing Committee conducts an evidence review and consultations. Finally, actors may directly lobby Members of Parliament (MPs) who will vote on the bill once the Standing Committee report is tabled. Gap between rules and actual policy making. However, multiple participants highlight the gap between the formal rules and the actual ways policies are developed. We have a lot of policies and whether decision makers use them to implement or make decisions is another question. (V25, Government) There was one example of a health-related legislation […] The amendment was proposed, drafted, all in the absence of MoH. Virtually a night before it was proposed to Parliament, someone gave a copy to MoH: “just let you know, this is what’s going to happen tomorrow.” (F34, Development partner) The data suggest several conditions that might be behind this phenomenon, described in the following. Centralised decision-making in Fiji. Participants indicated that the political elite, who gained power in the last coup, hold significant decision-making authority in the current government. Centralisation of authority within the government is quite apparent, for example, the Attorney-General (AG) serves as the Minister for Economy, Civil Service, Communications, and Housing and Community Development, while the PM is also the Minister for Sugar Industry, Foreign Affairs, iTaukei Affairs, and Forestry ( 51 ). It will be really just decided by the AG. (F34, Development partner) Either the PM, or the Minister for Economy. They are the ones who will make the final decision in terms of the policy formulation. (F21, Government) Inadequate consultations . The data indicate that in both countries, consultations are often conducted inefficiently, involve only a few actors, are held too late in the policy process, or actor input is not incorporated. Just a few people came in […] But it does not matter if people come or not, we just had to prove that it was done. (F04, Government) Limited capacity or intention for stakeholder involvement. The data suggest that actor engagement might be poor, not because of capacity or organisational issues, but because the agency might not have any real intention of considering other opinions and interests. In Fiji, this is explained as a remnant of the military regime. The government is not used to a process of consultations before they make decisions. […] [It] is making some attempts to change, but I think in some areas they do not want to consult. (F34, Development partner) In Vanuatu, there is often no intention to implement the policy paper itself, just to support funding requests towards development partners. It's just kind of ‘all right, let's get the policy document in place. Then we'll go on with the work we were doing anyway’, rather than identifying it as an opportunity to put in place some real change. […] It was like, we just need to write something, and the more people we involve, the more time it will take, and we do not have time. (V15, Government) Limited stakeholder capacity for meaningful contribution. Other data showed that when consultations or intersectoral meetings are held, they do not necessarily bring the desired input, either because relevant actors might not attend or not contribute meaningfully to the discussion. We took [the policy draft] to a stakeholder consultation after it was written. They were generally like, 'yeah, looks good'. Again, I still do not think people in that room read it. […] There were about 40 actors from across the public sector, NGOs and to the private sector. (V15, Government) When MoH calls Finance, Trade, Planning to come for a meeting, these guys do not even come or they send a small officer who cannot take any decision. (F28, Development partner) 3.2.2. Terms of engagement with the tobacco industry Lack of official terms of engagement. According to the MANA dashboard, Vanuatu has no tobacco industry interference policies in place, while Fiji is in the process of developing one ( 27 ). However, neither the interviews nor the document analysis reflected any progress on this front. Regular interaction and inadequate transparency measures. The lack of terms of engagement is particularly problematic in light of the close relationship between the tobacco industry and government agencies in Fiji and Vanuatu ( 17 , 33 ), and because in both countries, the administrative procedures – for obtaining and maintaining registration and licensing of the tobacco industry – requires MoH to interact with industry representatives. They [tobacco related businesses] renew their licences through the ministry [MoH], so if they have any issues with the packaging or that kind of things, they have to liaise with the ministry. (F06, Government) Firstly, they [tobacco industry] have to go to the Vanuatu Investment Promotion Authority to apply for a permit. […] The Department of Industry comes in when it comes to processing tobacco, but for the planting they need to talk to MoA. They also need to talk with the MoH to see their regulations. (V16, Government) Without implemented transparency measures, this provides an opportunity for the tobacco industry to influence high-level policy makers. For example, in 2018, tobacco industry representatives met with the Minister for Health to secure MoH endorsement for establishing the first tobacco factory in Vanuatu. No transparency measures were in place, and the industry representatives left with a signed supporting letter [paraphrased, V17]. In 2020, the same precedent was repeated ( 52 , 53 ). Limited screening for individual conflicts of interest. MoH in Fiji has a procedure in place to screen prospective administrators for individual conflicts of interest related to tobacco. They [MoH] are very careful about it; they do not employ people coming from pro-tobacco sector. They do a very thorough check on the applicants. (F06, Government) However, such a mechanism is not applied in the Ministry of Economy or Agriculture, as the hiring of ex-BAT employees to high-level positions indicates ( 54 , 55 ). The Head of Procurement in the Ministry of Economy is someone who has come from British American Tobacco. ( 55 ) In Vanuatu, the interviews reflected no process in place to filter out applicants with conflicts of interest. Limited oversight from third parties. Oversight by third parties (CSOs or development partners) or the public may limit vested interest influence over policy makers. However, no transparency and accountability measures are in place in Fiji and Vanuatu, and no tobacco industry watchdog or tobacco control-related CSO operates in these countries. Not only in tobacco, but they do not have any CSOs which are looking into NCDs at all. (F27, Development partner) No awareness raising or lobby transparency measures on tobacco industry interference. Neither Fiji nor Vanuatu has any activities on awareness raising of industry interference practices, and no lobby transparency measures are in place either [paraphrased, F26]. The only monitoring happens by the NCD officer at WHO [in Suva]. She Googles it and then lets MoH know. But in the Ministry [MoH] nobody does it. (F06, Government) These findings show that in terms of the policy and legislative process, although the rules on paper should ensure stakeholder involvement, there are conflicting perceptions on actual practice. Official terms of engagement with the tobacco industry are not in place, despite these countries' obligations to fulfil FCTC Article 5.3. While some MoH officials adhere to the principles of Article 5.3, there are examples where high-level MoH officials and other government agencies do not follow the recommended terms of engagement. As no CSO operates in tobacco control advocacy in Fiji and Vanuatu, third-party oversight is difficult to establish. While the official safeguards in the policy and legislative process are encouraging, the fact that they may not be adequately followed and terms of engagement are not in place are concerning for tobacco control policy making. The tobacco industry tends to employ powerful and well-tested strategies to influence policy makers ( 56 ), and without government mechanisms to protect policy makers from their influence and enable potentially less powerful actors to elevate public interests, health sector actors are likely to be in a very difficult situation when they try to establish regulatory tobacco control measures. 3.3. Checks and balances Weak Parliament and limited oversight. In Fiji, Parliamentarians’ capacity building through trainings provided by development partners has been in progress since democratic institutions were reinstated in 2014 ( 57 ). Although Vanuatu has had democratic institutions since its independence in 1980, its Parliamentary mechanisms are still under development: not only do the MPs need to be trained on the legislative procedures, but the technical and procedural capacity of the Standing Committees needs improving ( 57 ). Consequently, the Parliament in Vanuatu is considered weak, and participants state that the government (the ruling party) controls it. No one is really knowledgeable in the Parliament at the moment. […] Nobody knows what they should be doing. […] They do not have any support, because there is no committee staff, which are the spine of the work in committee. […] About the autonomy of Parliament, there's a huge lack to that extent in Vanuatu. Government is completely controlling the Parliament. […] There is no Parliamentary oversight. (V11, Development partner) In Fiji, strict confidentiality rules protect policy makers from needing to disclose information to other government agencies or the Parliament which limit their oversight. Whatever decisions do not reach the Parliament from the Cabinet, it is mostly because it is confidential. […] Cabinet information is only released after prior approval from the PM and the Secretary of the Cabinet. (F07, Government) Limited judicial and executive oversight. In both Fiji and Vanuatu, judicial oversight over the policy and legislative process is practised only when Constitutional rights are affected; the courts do not check whether the policy process was followed correctly. If to be a watchdog, to make sure that all the government functions are operating, no, the court does not do that. (V31, Government) The Supreme Court in Vanuatu has been noted to be independent of the Parliament; it has regularly prosecuted a high number of MPs for corruption ( 58 , 59 ). This indicates that the judiciary in Vanuatu tends to control corruption among MPs but does not exercise much oversight over the administration. The same proactivity is not so visible in the Fijian judiciary; a participant suggests that possibly the AG has influence over the courts [paraphrased, F35]. The executive oversight by the President has not shown any relevance in either state. The findings show that the system of checks and balances embedded into democratic governance appears to be muted: the Parliament, the Judiciary and the President in both countries seem to have limited control over the government. This might impede tobacco control, as these democratic institutions will have less influence to support health sector actors to protect public health interests from vested political interests in other fragments of the government that might be captured by the tobacco industry. 3.4. Bureaucratic autonomy Muted layers of decision-making and accountability in Fiji. As described earlier, the AG and the PM hold multiple important ministerial positions in Fiji. Moreover, the policy process is designed so that either the AG or the Minister for Economy needs to approve policies – the same individual since 2014. Additionally (or perhaps consequently), government agencies in general rarely initiate their own ideas but wait for the AG and the PM to identify priorities and issue areas. Some of the more traditional policy development type of functions what ministries would perform are really muted here [in Fiji]. In lot of instances ministries won’t actually provide or do any policy development […] Everything is really centrally controlled, even when it is related to individual actions of ministries, nobody takes any step forward unless its approved by him [AG]. (F34, Development partner) The role of political culture in policy makers’ limited proactivity in Fiji. Although decision-making should be practised at each administrative level vertically during the development of policy, these layers of decision-making are often muted in MoH in Fiji. According to participants, the PS tends to hold most decision-making power within the ministry. This might be complemented by the risk-aversion culture so heavily present in the Fijian civil service: officials often try to avoid making decisions to not make any mistakes that could result in losing their job [paraphrased, F34]. Given how often PSs change in MoH – arguably, the person who makes most decisions within the agency – it might look like a realistic fear: within MoH there were four PSs between 2016 and 2018, which shows that keeping a PS position in this ministry is challenging. A participant suggested that the Public Service Commission (controlled by the AG and the PM) changes the PS of MoH as soon as enough time has passed for the individual to understand how the sector works because that is when they could start to have independent ideas [paraphrased, F02]. Thus, by avoiding the responsibility for decision-making, the necessary layers of accountability are also lacking. Consequently, government officials often lack proactivity in policy development (F23, F34). It makes for a very difficult environment for civil servants to say, ‘we knew that was not the right way to go, but in fact we could not even provide that advice because it was not received that way’. Its interpreted as ‘you are not being supportive of what I want to do’. […] Ministers are saying that ‘nobody does anything until I ask them to do it’. But if anyone acts in a proactive way, they are not sure how they going to be received, therefore there is very little will from the public servants to be proactive. (F34, Development partner) Frequent changes in strategic direction. The muted layers of decision-making and accountability contribute to the frequent changes in MOH’s strategic direction when the top leadership rotates in Fiji and Vanuatu. The expectations to our department changes all the time, as the management changes, the action plan changes. (F09, Government) We had a change of minister about five times while I was in MoH in that two years. Which is incredibly frustrating. […] When a new minister would come in, we'd see an overhaul of what we were doing. (V15, Government) Although the data reflect that in Vanuatu department heads tend to retain a certain amount of bureaucratic autonomy. You'd see some things come through, when the minister said that we need to work on this, and you're like, ‘Okay, but it's not in the policy, It's not in the strategy, nor is it in our business plan for this year. So do we really need to work on it now?’ And it was ‘well, yes.’ So if the things that come from below their level, they generally got a fair bit of autonomy to do what they like, but for things that come from above by the DG or the minister, they generally a bit more propelled into doing it, whether they agree with it or not. (V15, Government) Public service reforms but with similar issues in Fiji. The Ministry of Civil Service recognised the nuisance of the lack of autonomy that resulted from the muted layers of decision-making and accountability; it has attempted to salvage this issue through a series of public service reforms since 2016. However, participants explain that the way the reforms are planned seems to contradict their aim to give more responsibility to lower-level executives. It’s part of the narrative you hear from the AG and the PM that they want to do things differently […] ultimately to achieve different results, you got to act in different way. […] I can also understand that moving from a military style government into a new government is a very different way of doing things. (F34, Development partner) The PSs are responsible for planning and implementing such reforms in their respective ministries, and in MoH even the Deputy Secretaries and Department Directors are excluded from this planning and decision-making process [paraphrased, F08, F14]. In summary, in Fiji, the centralisation of decision-making authority and the political culture leave little bureaucratic autonomy in the hands of policy makers. These findings are concerning for tobacco control because even if administrators are “public-interested”, they have little autonomy to ensure that health interests are elevated in tobacco governance. In Vanuatu, strategic priorities often change due to the frequently changing political landscape, resulting in a heavy rotation of high-level MoH officials. This is likely to disrupt the strategic elevation of health interests in intersectoral governance. 3.5. Capability to analyse policy alternatives for public interest Government agencies are able to conduct their own analysis to determine the most beneficial policy alternatives for the public and avoid excessive reliance on the information provided by particular actors (such as tobacco industry) only if they have adequate human, technical, financial and administrative capacity. However, MoH in both Fiji and Vanuatu faces capacity issues often visible in SIDS. Limited human capacity. While in larger LMICs often an entire unit is responsible for tobacco control, due to small populations, in SIDS there is often one person dedicated to NCDs or tobacco control; thus, smoking is likely to receive less attention [paraphrased, F27]. In Fiji and Vanuatu, tobacco control receives limited resources. There is one government official dedicated full time to tobacco control policy making and a number of environmental health officers work on ensuring compliance; however, long-term vacancies in these positions are common. This is likely to have a detrimental effect on the agency's performance. We have a very good policy environment in Vanuatu for public health. It’s just that there are limited human resources. It is difficult with the scattered islands. (V30, Government) Limited technical capacity. Acquiring the necessary technical skills in areas related to tobacco governance is challenging in Fiji and Vanuatu due to the limited higher education courses available in local universities. Thus, finding policy makers with the required skills takes time. The Director of Planning just came in like less than six months ago. Prior to that, that post has been vacant for the past three to four years. (V29, Government) One person has been negotiated agreements, but he now has left. So we don't have any trading negotiations now; we have no trade negotiators. (V25, Government) Low financial capacity. The low financial resources dedicated to NCDs are commonly seen as a barrier to strengthening tobacco control. Even though the government declared that there is an NCD crisis, not only in Vanuatu but in the whole Pacific, when it comes to sharing the funds, still communicable diseases receive more money. (V12, Government) Issues in performance management and accountability. Participants expressed their opinion that performance management and accountability issues constrain administrative capacity within the government. I do not think we have enough good people in the right positions in government. I think the workplace culture in Vanuatu in the government is not very conducive to having performance determine your position. Basically, people can be underperforming and it's never picked up, and it happens all the time (V25, Government) These findings show that SIDS vulnerabilities have a detrimental impact on health sector actors' capability to analyse policy alternatives for public interest. Although human and financial resource problems are conditions commonly observed in LMICs, the data demonstrate that in Fiji and Vanuatu such issues are aggravated by geographical isolation, the small size of the population and its economy, and the logistical and financial challenges of distributing services across several islands. This is concerning for tobacco control because when a careful analysis of the policy alternatives is not conducted, policy makers remain vulnerable to vested interests they aim to regulate. [1] Second-in-command in a ministry in Fiji, the equivalent of DG in Vanuatu. 4. Discussion This paper explored the institutional conditions that shape health sector actors’ ability to protect public health interests in multisectoral tobacco governance in Fiji and Vanuatu. Our study contributes to the commercial determinants of health, health governance and development literature by shedding light on the connection between SIDS vulnerabilities, political context, and government structures, rules, and accountability in multisectoral policy development for tobacco control in Fiji and Vanuatu. Previously no similar study has been published on PSIDS that would provide a theory-informed, interdisciplinary analysis of the institutional conditions that shape the ways tobacco is governed. 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 the political parties contributes to the politicisation of government in both states, resulting in the questionable “public-interestedness” of high-level government officials. The system of checks and balances embedded into democratic governance appears to be muted, and policy makers have limited bureaucratic autonomy to elevate health interests in multisectoral policy making amidst the frequent rotation of high-level government officials. Capacity constraints aggravated by SIDS vulnerabilities negatively impact health sector actors' capability to analyse policy alternatives. The findings show that SIDS vulnerabilities have a major impact on the ways institutions are structured and operate in both states. In Vanuatu, clientelism and patronage are consequences of the country being scattered over multiple little islands, and due to the weak regulation of political parties, the political landscape rapidly changes in the country. As a result, individuals in executive government positions do not necessarily govern for public interest but their personal, political, or localised interests. Fiji, being a post-authoritarian state, has a centralised government system where the ministries are highly dependent on the AG's discretion, and since he tends to prioritise commercial interests, this constrains MoH from elevating health interests in tobacco governance. These political conditions negatively impact the performance management and accountability mechanisms of these countries, which are further burdened by the weak human and financial capacities common in SIDS. The consequences are twofold. Firstly, the rules of policy making – which could ensure the protection of public health interests – are often not followed, and there are no terms of engagement implemented with the tobacco industry. Secondly, health sector actors have limited capacity and capability to make well-informed policy choices. 4.1. Contribution to the literature Our findings confirm a previous study reporting that SIDS vulnerabilities make these countries susceptible to the influence of vested interests ( 31 ). This makes the careful examination of policy alternatives in multisectoral tobacco policies challenging. Consequently, government agencies are likely to rely on the readily available information provided by the tobacco industry or development partners. Prior research in tobacco control in PSIDS reported on the detrimental impact of capacity issues on policy making and implementation ( 32 , 60 , 61 ). Other studies focusing on food policy in PSIDS had similar results; they showed that limited human and financial capacity is a major barrier to the development of multisectoral food policies ( 41 , 62 – 64 ). Our study provides new depth to these insights by analysing how SIDS capacity constraints limit health sector actors' capability to implement and participate in policy and legislative processes that could ensure a level playing field if adequately employed. The governance and development literature ( 65 – 73 ) has recognised that LMICs often establish democratic institutions as the means to become more legitimate for the public and development partners, while in reality the way the country is governed relies on old, informal mechanisms, usually dominated by a political elite. Levitsky and Murillo ( 72 ) call this parchment reforms, when “ rules exist on parchment, but in practice, they do little to constrain actors or shape their expectations ”. Pritchett et al. ( 67 ) describe this as "isomorphic mimicry, wherein the outward forms (appearances, structures) of functional states and organisations elsewhere are adopted to camouflage a persistent lack of function." This could help understand why there is a gap between the rules and reality of policy making in Fiji and Vanuatu; however, our study has expanded this understanding by explaining that it is not mere political calculations that are behind such façade but a complex interplay of SIDS vulnerabilities. 4.2. Implications for policy Strengthening human, technical and financial capacity. Multiple development partners work together with the governments of Fiji and Vanuatu to build human, technical and financial capacity, including strengthening tobacco control. However, as the data revealed, NCD prevention receives less financial assistance than other areas of health and do not target civil society. Funding CSOs to operate in this field in PSIDS would be an important step in strengthening health sector actors’ capacity to protect public health interests. Increasing the human, technical and financial capacity of MoH would support well-informed policy choices; it would provide adequate capacity to meaningfully follow the policy process, implement terms of engagement, and present more evidence on the harmful impact of supporting the tobacco industry. However, capacity building efforts must be sensitive to the cultural context of PSIDS ( 74 ). These insights are aligned with prior suggestions to build capacity in PSIDS to strengthen tobacco control ( 32 , 60 , 61 ). However, our findings imply that capacity building is unlikely to bring the desired outcomes without strengthening governance. Strengthening performance management and accountability mechanisms. Our study suggests that performance management and accountability mechanisms need to be strengthened via governance strengthening programmes such as those often provided by development partners. This would ensure that the carefully planned policy processes are followed, and it would improve the implementation of FCTC, which could result in the development of terms of engagement with the tobacco industry. This recommendation is aligned with CDoH scholars’ suggestions ( 75 , 76 ), highlighting the need for robust accountability mechanisms to regulate harmful commodity industries; moreover, it corresponds to development scholars’ works ( 65 , 68 , 69 ), emphasising that government strengthening is essential to address the gap between the rules of policy making and their implementation. Governance strengthening initiatives are frequently provided by development partners to LMICs, and there have been examples of such programmes in Fiji according to the collected data; however, the political elite has been selective on which recommendations of the development partners to follow, which leads to the next insight of this study. Strengthening the rules of the political system. While this research mainly focused on governance in Fiji and Vanuatu around tobacco, the results suggest the need to strengthen the political system's regulation. The tightening of the regulation of the political parties and strengthening the Parliament is necessary for PSIDS for the institutional conditions to ensure the protection of public interests. In both Fiji and Vanuatu, Parliamentary capacity needs to be improved to enable oversight over the government to facilitate public-interested policy making and that the governance strengthening programmes bring the desired results. In Vanuatu, regulation of the political parties must be strengthened to decrease clientelism, patronage, and frequent rotation among high-level government officials. In Fiji, the transition to full democracy should be encouraged: the political elite needs to be persuaded to let go of its control – the data showed that there had been relevant developments; thus, a complete transition to democracy is undoubtedly on the cards for Fiji. 4.3. Limitations This study was constrained by the funding and time restrictions of being a doctoral project. This resulted in several limitations. First, we have not had the resources to formally include local Fijian or ni-Vanuatu researchers. This limitation was mitigated by successfully requesting substantial guidance from government officials in MoH in Fiji and Vanuatu. Second, only two case studies were included in our study. This has a detrimental impact on the generalisability of the findings but allows the exploration of the institutional conditions shaping health sector actors’ capability to protect health interests in tobacco governance. 5. 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. Changing the institutional conditions is a slow and lengthy process, but initiatives focusing on some relevant areas are already underway in Fiji and Vanuatu. Declarations Ethics approval and consent to participate: Research Ethics approval was granted for this study by the Fiji National Health Research and Ethics Review Committee, the Vanuatu Cultural Centre, and the Australian National University Human Research Ethics Committee (protocol number: 2017/945). Written informed consent was received from all participants to be involved in the study as per the approved Ethics protocol. The Ministry of Health and Medical Services of Fiji and the Ministry of Health of Vanuatu endorsed this study. Consent for publication: Not applicable. Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests. Funding: The Australian National University provided funding for Dori Patay to undertake this doctorate research under its University Research Scholarship, The Australian National University Higher Degree by Research Fee Remission Merit Scholarship, The Australian National University Vice Chancellor’s Travel Grant schemes. Grant number is not applicable. Authors' contributions: DP: Conceptualisation; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Validation; Visualisation; Roles/Writing - original draft. SF: Supervision; Writing - review & editing. AS: Supervision; Writing - review & editing. All authors read and approved the final manuscript. Acknowledgements: We thank the Dr Dip Chand and the late Dr Isimeli Tukana of the Ministry of Health and Medical Services of Fiji, and Dr Len Tarivonda of the Ministry of Health of Vanuatu for their guidance on this project. References Global Burden of Disease Collaborators. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2164081","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research","associatedPublications":[],"authors":[{"id":148309873,"identity":"7161cecd-7e5b-4d37-9a41-24a332e79595","order_by":0,"name":"Dori Patay","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA70lEQVRIiWNgGAWjYDCCA2AEAswH4CJEaZFgYGBLIF4LA0QLjwFxWviO9z48wLjDro5/Rs7Hz4VtDHJ8NxIYP/Pg0SJ55rjBAcYzyRISN3I3S89sYzCWvJHALI1Pi8GNNIYDjG3MEgw3cjdI87YxJG64kcBAjJZ6CfkbOY9/A7XUA7Uw/yZCy2EJgxs5bCBbEgxuJLDhtUXyzDGGA4lnjktuPPPMzJrnnIThzDMP2yzn4NHCd7yN+cPHHdX8cseTH9/mKbOR5zuefPjGGzxawCCxAUgIJICYwPhhYGwgpAGqhv8AYYWjYBSMglEwMgEA7ZxQyu9yitcAAAAASUVORK5CYII=","orcid":"https://orcid.org/0000-0001-5927-1006","institution":"Australian National University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Dori","middleName":"","lastName":"Patay","suffix":""},{"id":148309874,"identity":"b5a7357d-8ead-4fe7-8ad6-1dabb3371d02","order_by":1,"name":"Ashley Schram","email":"","orcid":"","institution":"Australian National University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ashley","middleName":"","lastName":"Schram","suffix":""},{"id":148309875,"identity":"80b609db-f9c3-4d89-a5d5-53ab51b54614","order_by":2,"name":"Sharon Friel","email":"","orcid":"","institution":"Australian National University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Sharon","middleName":"","lastName":"Friel","suffix":""}],"badges":[],"createdAt":"2022-10-13 23:52:40","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2164081/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2164081/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12992-023-00931-y","type":"published","date":"2023-04-28T20:36:06+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":44729848,"identity":"149ae4bd-256e-493e-b01d-f5ed24864534","added_by":"auto","created_at":"2023-10-16 21:21:24","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":681516,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2164081/v1/98d080f5-17fc-4c9d-bce6-1b340c7334b4.pdf"}],"financialInterests":"","formattedTitle":"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.","fulltext":[{"header":"1. Background","content":"\u003cp\u003eThe noncommunicable diseases (NCDs) epidemic is a major burden for societies and health systems globally (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). NCDs not only hinder global efforts to reach the United Nations Sustainable Development Goal (UN SDG) 3 (Good Health and Wellbeing) (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e); they also incur high socioeconomic costs through the disability and loss of productivity resulting from morbidity and premature deaths, which hamper economic development and makes reaching other SDGs even more challenging (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Therefore, tackling the drivers of this NCDs epidemic is important not only for health but economic and development purposes.\u003c/p\u003e \u003cp\u003eThe increased consumption of harmful commodities including tobacco, alcohol and ultra-processed foods drives the global rise of NCDs (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). The need to regulate the commercial determinants of health (CDoH) \u0026ndash; the systems, practices and pathways through which commercial actors increase the availability, affordability, accessibility and demand for harmful commodities (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) \u0026ndash; has been recognised by public health scholars (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). However, many countries struggle with both the development and implementation of the necessary multisectoral regulatory policies (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Thus, the capability of health sector actors to protect and elevate public health interests in multisectoral policy making is crucial in governing CDoH.\u003c/p\u003e \u003cp\u003eDemocratic governments tend to provide multiple opportunities for actors to advance their interests in policy making. This can enable health sector actors to influence non-health sector policies such as trade, industry, agriculture, or economic to optimise their public health impact. However, these processes also provide a chance for commercial actors to formally influence policy makers (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), where their aim is to ensure a policy and regulatory environment that favours their interests (so-called industry interference) and maximises profits (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). This has been recognised as a major challenge for public health, as these actors\u0026rsquo; profit-oriented interests often conflict with public health interests.\u003c/p\u003e \u003cp\u003eDespite whole-of-government mechanisms that should provide an opportunity for health sector actors to elevate health interests in multisectoral governance (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), and the recommendations of the Framework Convention on Tobacco Control (FCTC) Article 5.3 on the establishment of terms of engagement to protect public health policy making from tobacco industry interference (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), health sector actors continue to struggle with protecting public health interests in tobacco governance in many countries (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHealth sector actors in low- and middle-income countries (LMICs), where economic development is often the primary concern of governments and is led by the narrow interpretation of economic norms (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e), are in a particularly difficult situation and often fail to ensure the priority of public health interests over tobacco industry interests (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). This is a significant issue as LMICs experience 77% of the global mortality from NCDs (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Tobacco use itself is predicted to kill 8\u0026nbsp;million people annually by 2030, and 80% of these deaths will happen in LMICs (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSmall island developing states (SIDS) are a unique group of LMICs situated in three geographical regions: the Caribbean, the Pacific, and Africa, Indian Ocean, Mediterranean and South China Sea (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). SIDS have unique socioeconomic, political, and geographic conditions \u0026ndash; often called SIDS vulnerabilities \u0026ndash; that make their development particularly challenging (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). These SIDS vulnerabilities, that set them apart from other LMICs, include the small size of their land, population and economies; geographic isolation (from other countries and between islands of the same state); governments that are small in size (fitting to the scale of the population) and with limited human, technical and financial resources; low administrative capacity; infrastructural challenges of travel and supply of goods and services, and their dependence on the policies and conduct of larger economies in their region (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePacific small island developing states (PSIDS) declared an NCD crisis in 2011 (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Despite the majority of PSIDS adopting the Tobacco Free Pacific 2025 Goal (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), the rate of current smokers among males reaches as high as 54\u0026ndash;74% in some states \u0026ndash; in contrast to the global average of 22% (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan additionalcitationids=\"CR24 CR25\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Previous research has shown that PSIDS face challenges in implementing multisectoral NCD prevention policies (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e), and that their SIDS vulnerabilities potentially aggravate government fragmentation and their susceptibility to tobacco industry influence (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan additionalcitationids=\"CR30\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eUnderstanding the ways institutional conditions \u0026ndash; the structures and attributes of governance systems \u0026ndash; can support health sector actors to protect health interests against powerful harmful industry interests in possibly the world\u0026rsquo;s smallest countries is a vital step to tackling the NCD crisis. Yet, the literature on public health policy making in PSIDS provides limited analysis of institutional conditions that affect multisectoral governance (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Particularly, scholarship on tobacco control policy making is PSIDS is scarce (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Therefore, this paper aims to explore the institutional conditions in PSIDS \u0026ndash; Fiji and Vanuatu in particular \u0026ndash; that shape health sector actors\u0026rsquo; capability to protect public health interests in multisectoral tobacco control policy making. This study was conducted as part of a larger research project investigating the ways interests, ideas, and institutions shape multisectoral tobacco governance in Fiji and Vanuatu (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e).\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003eWe applied a theory-informed, qualitative, exploratory research design in this study.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Theoretical perspective\u003c/h2\u003e \u003cp\u003eData collection and analysis were guided by Croley\u0026rsquo;s administrative process theory (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e), which arose from new institutionalist scholarship that interprets governance through the operation of institutions (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). The administrative process theory claims that policy makers can ensure that governance is not dominated by vested interests if five conditions are in place: (i) the policy makers are \u0026ldquo;public-interested\u0026rdquo;; (ii) policy making processes ensure a level playing field between actors; (iii) extra-legislative mechanisms, such as judicial reviews and presidential oversight, help maintain policy maker\u0026rsquo;s autonomy from politics; (iv) policy makers have considerable bureaucratic autonomy (both from politicians and other dominant fractions of the government); and (v) policy makers have the capacity and capability to conduct a careful analysis of policy alternatives (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Study design, data collection and analysis\u003c/h2\u003e \u003cp\u003eAn exploratory, qualitative case study approach incorporating within-case analysis and cross-case synthesis was applied (\u003cspan additionalcitationids=\"CR37\" citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Prior tobacco control and food policy studies successfully employed a similar approach in PSIDS (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan additionalcitationids=\"CR40 CR41\" citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTo identify case study countries where health sector actors potentially succeeded in protecting public health interests in tobacco governance, first, we selected PSIDS with recent progress in implementing FCTC measures that regulate the tobacco industry, using WHO MPOWER reports (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). Then, PSIDS with likely divergent interest in tobacco governance were identified: Fiji was chosen as a country where commercial tobacco farming and manufacturing were detected based on tobacco-related exports (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e); Vanuatu was selected as a county without an established tobacco industry but with interest in investing in these sectors, through a Google search.\u003c/p\u003e \u003cp\u003eThe Republic of Fiji has a population of near 900,000, scattered over approx. 110 islands (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e). Since regaining independence from the British Empire in 1970, its politics has been characterised by a series of coups, with the latest in 2009 (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). In 2014, the democratic government was reinstated (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). British American Tobacco (BAT) has two processing plants in Fiji, and it has a close relationship with the political elite (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe Republic of Vanuatu counts a population of approx. 410,000 and 65 inhabited islands (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e). From colonisation to 1980, the country was ruled as a joined Anglo-French Condominium (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e). Since then Vanuatu has been characterised by frequently changing governments (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e). Vanuatu has no commercial tobacco farming or manufacturing, but interest in investing in these activities was reported (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eData was collected through in-depth interviews between April 2018 and August 2019. A purposive and snowball selection process was applied, targeting participants from government agencies in health, agricultural, trade, industry, finance, and education sectors, civil society organisations; local academic institutions; development partners (intergovernmental and regional organisations, and governmental agencies of donor countries); and the tobacco industry. Most interviews were conducted in person and a few over Skype, with an average duration of 60 minutes. The interview questions were open-ended and semi-structured. The transcription of the interviews was coded against the claims of the administrative process theory constructs in NVivo. The data was triangulated by follow-up interviews and the analysis of relevant parliamentary debates and policy documents.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eForty-two interviews were conducted in Fiji and 28 in Vanuatu; 21 invitees (including the tobacco industry) declined participation. The number of interviews based on actor type and country is provided in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The following presents the results across Croley\u0026rsquo;s five conditions.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe distribution of interviews\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eFiji\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eVanuatu\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eType of actor\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGovernment agencies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCivil society organisations \u0026amp; academic institutions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDevelopment partners\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003e\u003cb\u003ePolicy sector\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHealth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTrade/Industry\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgriculture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFinance/Economy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEducation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eForeign Affairs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMultisectoral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e3.1. Low \u0026ldquo;public health-interestedness\u0026rdquo;\u003c/h2\u003e \u003cp\u003e \u003cb\u003eHigh-level government officials are perceived to have low \u0026ldquo;public health-interestedness\u0026rdquo;.\u003c/b\u003e Overall, in Fiji and Vanuatu, participants state that government officials at the highest levels are caught up in politics, which often has detrimental effects on their \u0026ldquo;public health-interestedness\u0026rdquo; in tobacco control policy making. Others suggest that pursuing short-term economic benefits serve high-level government officials\u0026rsquo; political interests more than long-term health benefits.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003ePeople up the top there do not take [tobacco control] seriously enough. Who is on top? PS [Permanent Secretary] and Minister for Health. (F06, Government)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eNow it\u0026rsquo;s only the \u0026ldquo;technicians\u0026rdquo; who want to move things, but there is not a real drive from the top. The top is focused on winning the elections and building economic growth. (F28, Development partner)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eClientelism and patronage as possible drivers of low \u0026ldquo;public-interestedness\u0026rdquo;.\u003c/b\u003e Clientelism is the \u0026ldquo;\u003cem\u003eproffering of material goods in return for electoral support\u0026rdquo;\u003c/em\u003e (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e), and patronage means the \u0026ldquo;\u003cem\u003eexchange of a public sector job for political support\u0026rdquo;\u003c/em\u003e (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e). In Vanuatu, SIDS vulnerabilities, such as the country's small population and land size and geographical layout (i.e., scattered over several islands, which causes infrastructural challenges), the weakness of the government and its developing economy contribute to the limited reach and efficiency of public services. Consequently, communities perceive that they only benefit from politics if their representative gets elected to Parliament. Thus, these vulnerabilities make SIDS particularly conducive to clientelism.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003ePolitics is localised. Every small place tries to choose someone from their area in the hope that that person will bring them something or they'll accept some form of bribe to vote to that person again, because it's the only thing they see, they do not get much in services. (V13, Government)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eWeak political part regulation contributing low \u0026ldquo;public-interestedness\u0026rdquo;.\u003c/b\u003e Low \u0026ldquo;public-interestedness\u0026rdquo; was also seen as being shaped by weak political party regulation contributing to corruption, and frequent political power changes. The regulation of the ways political parties operate \u0026ndash; who is allowed to have a political party, how do you create and fund a political party? \u0026ndash; is weak in Vanuatu. Consequently, and also fuelled by the geographically fragmented constituency (another SIDS vulnerability), 24 parties were operating in 2014, with this number decreasing to 17 in 2016. To form a majority government, parties need to form coalitions, and high-level government positions are often offered in exchange for support (i.e., patronage).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eThere are many different political parties. [\u0026hellip;] In Parliament you need to build a majority, so the main group in power will try to build a coalition and they will just buy off the people: \u0026ldquo;Come I will give you a minister post\u0026rdquo;. (V11, Development partner)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAs a result of patronage, important positions in the government might be given to people who are neither skilled nor have the experience for the job.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eI do not think there's anything that's in the decision-making in the government that is not politicised. Even hiring people, especially jobs that are high-level positions. It's not actually what you can bring to the table, but it's who you know. (V27, Development partner)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eThe Ministers of Health over many years have been all sorts of people who do not have any interest or knowledge. (V13, Civil society)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn addition, and due to the limited political system regulation, political power structures frequently shift in Vanuatu: the Prime Minister (PM) was changed seven times between 2008 and 2012 and four times between 2012 and 2016. The PM, between 2016 and 2020, stayed in his role but had to fight off several attempts of impeachment by the Parliament. As political alliances frequently shift in Vanuatu, high-level government offices often change hands; those occupying them are aware of the possibility of short-term duration and, thus, may prioritise personal political interests instead of public interests.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eOne of the issues is that most of them only think about their political interests, parties\u0026rsquo; interests, but not national interest. (V11, Development partner)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e\u003cstrong\u003e\u0026ldquo;Public-interestedness\u0026rdquo; from below.\u0026nbsp;\u003c/strong\u003eHowever, there was a phenomenon of \u0026ldquo;public interestedness\u0026rdquo; from below, that is, mid-level Ministry of Health (MoH) officials that stayed in one position for a significant length of time tended to be \u0026ldquo;public-interested\u0026rdquo;. While the Ministers in Fiji and Vanuatu and the Permanent Secretaries[1] (PSs) in Fiji have often changed several times a year, other lower executive and mid-level officers tend to serve for a longer period. The Department heads in both countries and the Director-General (DG) of MoH in Fiji are held in high regard for being public-interested.\u0026nbsp;\u003c/p\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eThe DG has been kind of steering a steady ship at times that has been captured by ministers that do not really understand health in any way. (V15, Government)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe progress in tobacco control in both Fiji and Vanuatu were often explained by the personal leadership of these mid-level government officials to sustain MoH efforts despite the challenges posed by the high-level government officials\u0026rsquo; low \u0026ldquo;public-interestedness\u0026rdquo;\u003c/p\u003e \u003cp\u003eThe findings around \u0026ldquo;public-interestedness\u0026rdquo; show that the clientelism and patronage in both countries \u0026ndash; aggravated by SIDS vulnerabilities and weak regulation of the political space \u0026ndash; can result in high-level MoH officials in power who are not necessarily motivated by the public but rather personal or political interests. This might be a significant impediment to protecting public health interests when it comes to intersectoral negotiations on multisectoral policies, although \u0026ldquo;public interestedness\u0026rdquo; from below (by mid-level government officials) may mitigate this problem.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e3.2. Policy making procedures\u003c/h2\u003e \u003cp\u003eDemocratic policy processes should ensure a level playing field and multiple opportunities for actors to influence policy development (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e), and Article 5.3 of FCTC requires the establishment of terms of engagement to protect public health policies from tobacco industry influence (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). This section presents how the policy making procedures of Fiji and Vanuatu fulfil these requirements.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003e3.2.1. Policy and legislative process\u003c/h2\u003e \u003cp\u003e \u003cb\u003eFormally, the policy and legislative process offer several opportunities for intersectoral negotiations in Fiji and Vanuatu.\u003c/b\u003e The data reveal at least four opportunities when health sector actors can elevate public health interests: two were identified during policy development and another two in the legislative process. First, during the policy development, consultations must be conducted with the public and relevant actors.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eThe government will never accept anything if it didn\u0026rsquo;t go through consultations with public, NGOs, government departments, sellers, producers, importers, everybody. (F03, Government)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSecond, inter-ministerial discussions are to be held in the Cabinet (which in Vanuatu is preceded by an additional lower-level inter-ministerial meeting). If the policy is embedded into legislation, the third opportunity presents itself before the bill is debated in Parliament: a Parliamentary Standing Committee conducts an evidence review and consultations. Finally, actors may directly lobby Members of Parliament (MPs) who will vote on the bill once the Standing Committee report is tabled.\u003c/p\u003e \u003cp\u003e \u003cb\u003eGap between rules and actual policy making.\u003c/b\u003e However, multiple participants highlight the gap between the formal rules and the actual ways policies are developed.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eWe have a lot of policies and whether decision makers use them to implement or make decisions is another question. (V25, Government)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eThere was one example of a health-related legislation [\u0026hellip;] The amendment was proposed, drafted, all in the absence of MoH. Virtually a night before it was proposed to Parliament, someone gave a copy to MoH: \u0026ldquo;just let you know, this is what\u0026rsquo;s going to happen tomorrow.\u0026rdquo; (F34, Development partner)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe data suggest several conditions that might be behind this phenomenon, described in the following.\u003c/p\u003e \u003cp\u003e \u003cb\u003eCentralised decision-making in Fiji.\u003c/b\u003e Participants indicated that the political elite, who gained power in the last coup, hold significant decision-making authority in the current government. Centralisation of authority within the government is quite apparent, for example, the Attorney-General (AG) serves as the Minister for Economy, Civil Service, Communications, and Housing and Community Development, while the PM is also the Minister for Sugar Industry, Foreign Affairs, iTaukei Affairs, and Forestry (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eIt will be really just decided by the AG. (F34, Development partner)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eEither the PM, or the Minister for Economy. They are the ones who will make the final decision in terms of the policy formulation. (F21, Government)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eInadequate consultations\u003c/b\u003e. The data indicate that in both countries, consultations are often conducted inefficiently, involve only a few actors, are held too late in the policy process, or actor input is not incorporated.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eJust a few people came in [\u0026hellip;] But it does not matter if people come or not, we just had to prove that it was done. (F04, Government)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eLimited capacity or intention for stakeholder involvement.\u003c/b\u003e The data suggest that actor engagement might be poor, not because of capacity or organisational issues, but because the agency might not have any real intention of considering other opinions and interests. In Fiji, this is explained as a remnant of the military regime.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eThe government is not used to a process of consultations before they make decisions. [\u0026hellip;] [It] is making some attempts to change, but I think in some areas they do not want to consult. (F34, Development partner)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn Vanuatu, there is often no intention to implement the policy paper itself, just to support funding requests towards development partners.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eIt's just kind of \u0026lsquo;all right, let's get the policy document in place. Then we'll go on with the work we were doing anyway\u0026rsquo;, rather than identifying it as an opportunity to put in place some real change. [\u0026hellip;] It was like, we just need to write something, and the more people we involve, the more time it will take, and we do not have time. (V15, Government)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eLimited stakeholder capacity for meaningful contribution.\u003c/b\u003e Other data showed that when consultations or intersectoral meetings are held, they do not necessarily bring the desired input, either because relevant actors might not attend or not contribute meaningfully to the discussion.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eWe took [the policy draft] to a stakeholder consultation after it was written. They were generally like, 'yeah, looks good'. Again, I still do not think people in that room read it. [\u0026hellip;] There were about 40 actors from across the public sector, NGOs and to the private sector. (V15, Government)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eWhen MoH calls Finance, Trade, Planning to come for a meeting, these guys do not even come or they send a small officer who cannot take any decision. (F28, Development partner)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003e3.2.2. Terms of engagement with the tobacco industry\u003c/h2\u003e \u003cp\u003e \u003cb\u003eLack of official terms of engagement.\u003c/b\u003e According to the MANA dashboard, Vanuatu has no tobacco industry interference policies in place, while Fiji is in the process of developing one (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). However, neither the interviews nor the document analysis reflected any progress on this front.\u003c/p\u003e \u003cp\u003e \u003cb\u003eRegular interaction and inadequate transparency measures.\u003c/b\u003e The lack of terms of engagement is particularly problematic in light of the close relationship between the tobacco industry and government agencies in Fiji and Vanuatu (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e), and because in both countries, the administrative procedures \u0026ndash; for obtaining and maintaining registration and licensing of the tobacco industry \u0026ndash; requires MoH to interact with industry representatives.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eThey [tobacco related businesses] renew their licences through the ministry [MoH], so if they have any issues with the packaging or that kind of things, they have to liaise with the ministry. (F06, Government)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eFirstly, they [tobacco industry] have to go to the Vanuatu Investment Promotion Authority to apply for a permit. [\u0026hellip;] The Department of Industry comes in when it comes to processing tobacco, but for the planting they need to talk to MoA. They also need to talk with the MoH to see their regulations. (V16, Government)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWithout implemented transparency measures, this provides an opportunity for the tobacco industry to influence high-level policy makers. For example, in 2018, tobacco industry representatives met with the Minister for Health to secure MoH endorsement for establishing the first tobacco factory in Vanuatu. No transparency measures were in place, and the industry representatives left with a signed supporting letter [paraphrased, V17]. In 2020, the same precedent was repeated (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cb\u003eLimited screening for individual conflicts of interest.\u003c/b\u003e MoH in Fiji has a procedure in place to screen prospective administrators for individual conflicts of interest related to tobacco.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eThey [MoH] are very careful about it; they do not employ people coming from pro-tobacco sector. They do a very thorough check on the applicants. (F06, Government)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHowever, such a mechanism is not applied in the Ministry of Economy or Agriculture, as the hiring of ex-BAT employees to high-level positions indicates (\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eThe Head of Procurement in the Ministry of Economy is someone who has come from British American Tobacco.\u003c/em\u003e (\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn Vanuatu, the interviews reflected no process in place to filter out applicants with conflicts of interest.\u003c/p\u003e \u003cp\u003e \u003cb\u003eLimited oversight from third parties.\u003c/b\u003e Oversight by third parties (CSOs or development partners) or the public may limit vested interest influence over policy makers. However, no transparency and accountability measures are in place in Fiji and Vanuatu, and no tobacco industry watchdog or tobacco control-related CSO operates in these countries.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eNot only in tobacco, but they do not have any CSOs which are looking into NCDs at all. (F27, Development partner)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eNo awareness raising or lobby transparency measures on tobacco industry interference.\u003c/b\u003e Neither Fiji nor Vanuatu has any activities on awareness raising of industry interference practices, and no lobby transparency measures are in place either [paraphrased, F26].\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eThe only monitoring happens by the NCD officer at WHO [in Suva]. She Googles it and then lets MoH know. But in the Ministry [MoH] nobody does it. (F06, Government)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThese findings show that in terms of the policy and legislative process, although the rules on paper should ensure stakeholder involvement, there are conflicting perceptions on actual practice. Official terms of engagement with the tobacco industry are not in place, despite these countries' obligations to fulfil FCTC Article 5.3. While some MoH officials adhere to the principles of Article 5.3, there are examples where high-level MoH officials and other government agencies do not follow the recommended terms of engagement. As no CSO operates in tobacco control advocacy in Fiji and Vanuatu, third-party oversight is difficult to establish. While the official safeguards in the policy and legislative process are encouraging, the fact that they may not be adequately followed and terms of engagement are not in place are concerning for tobacco control policy making. The tobacco industry tends to employ powerful and well-tested strategies to influence policy makers (\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e), and without government mechanisms to protect policy makers from their influence and enable potentially less powerful actors to elevate public interests, health sector actors are likely to be in a very difficult situation when they try to establish regulatory tobacco control measures.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.3. Checks and balances\u003c/h2\u003e \u003cp\u003e \u003cb\u003eWeak Parliament and limited oversight.\u003c/b\u003e In Fiji, Parliamentarians\u0026rsquo; capacity building through trainings provided by development partners has been in progress since democratic institutions were reinstated in 2014 (\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e). Although Vanuatu has had democratic institutions since its independence in 1980, its Parliamentary mechanisms are still under development: not only do the MPs need to be trained on the legislative procedures, but the technical and procedural capacity of the Standing Committees needs improving (\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e). Consequently, the Parliament in Vanuatu is considered weak, and participants state that the government (the ruling party) controls it.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eNo one is really knowledgeable in the Parliament at the moment. [\u0026hellip;] Nobody knows what they should be doing. [\u0026hellip;] They do not have any support, because there is no committee staff, which are the spine of the work in committee. [\u0026hellip;] About the autonomy of Parliament, there's a huge lack to that extent in Vanuatu. Government is completely controlling the Parliament. [\u0026hellip;] There is no Parliamentary oversight. (V11, Development partner)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn Fiji, strict confidentiality rules protect policy makers from needing to disclose information to other government agencies or the Parliament which limit their oversight.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eWhatever decisions do not reach the Parliament from the Cabinet, it is mostly because it is confidential. [\u0026hellip;] Cabinet information is only released after prior approval from the PM and the Secretary of the Cabinet. (F07, Government)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eLimited judicial and executive oversight.\u003c/b\u003e In both Fiji and Vanuatu, judicial oversight over the policy and legislative process is practised only when Constitutional rights are affected; the courts do not check whether the policy process was followed correctly.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eIf to be a watchdog, to make sure that all the government functions are operating, no, the court does not do that. (V31, Government)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe Supreme Court in Vanuatu has been noted to be independent of the Parliament; it has regularly prosecuted a high number of MPs for corruption (\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e). This indicates that the judiciary in Vanuatu tends to control corruption among MPs but does not exercise much oversight over the administration. The same proactivity is not so visible in the Fijian judiciary; a participant suggests that possibly the AG has influence over the courts [paraphrased, F35]. The executive oversight by the President has not shown any relevance in either state.\u003c/p\u003e \u003cp\u003eThe findings show that the system of checks and balances embedded into democratic governance appears to be muted: the Parliament, the Judiciary and the President in both countries seem to have limited control over the government. This might impede tobacco control, as these democratic institutions will have less influence to support health sector actors to protect public health interests from vested political interests in other fragments of the government that might be captured by the tobacco industry.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.4. Bureaucratic autonomy\u003c/h2\u003e \u003cp\u003e \u003cb\u003eMuted layers of decision-making and accountability in Fiji.\u003c/b\u003e As described earlier, the AG and the PM hold multiple important ministerial positions in Fiji. Moreover, the policy process is designed so that either the AG or the Minister for Economy needs to approve policies \u0026ndash; the same individual since 2014. Additionally (or perhaps consequently), government agencies in general rarely initiate their own ideas but wait for the AG and the PM to identify priorities and issue areas.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eSome of the more traditional policy development type of functions what ministries would perform are really muted here [in Fiji]. In lot of instances ministries won\u0026rsquo;t actually provide or do any policy development [\u0026hellip;] Everything is really centrally controlled, even when it is related to individual actions of ministries, nobody takes any step forward unless its approved by him [AG]. (F34, Development partner)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eThe role of political culture in policy makers\u0026rsquo; limited proactivity in Fiji.\u003c/b\u003e Although decision-making should be practised at each administrative level vertically during the development of policy, these layers of decision-making are often muted in MoH in Fiji. According to participants, the PS tends to hold most decision-making power within the ministry. This might be complemented by the risk-aversion culture so heavily present in the Fijian civil service: officials often try to avoid making decisions to not make any mistakes that could result in losing their job [paraphrased, F34]. Given how often PSs change in MoH \u0026ndash; arguably, the person who makes most decisions within the agency \u0026ndash; it might look like a realistic fear: within MoH there were four PSs between 2016 and 2018, which shows that keeping a PS position in this ministry is challenging. A participant suggested that the Public Service Commission (controlled by the AG and the PM) changes the PS of MoH as soon as enough time has passed for the individual to understand how the sector works because that is when they could start to have independent ideas [paraphrased, F02]. Thus, by avoiding the responsibility for decision-making, the necessary layers of accountability are also lacking. Consequently, government officials often lack proactivity in policy development (F23, F34).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eIt makes for a very difficult environment for civil servants to say, \u0026lsquo;we knew that was not the right way to go, but in fact we could not even provide that advice because it was not received that way\u0026rsquo;. Its interpreted as \u0026lsquo;you are not being supportive of what I want to do\u0026rsquo;. [\u0026hellip;] Ministers are saying that \u0026lsquo;nobody does anything until I ask them to do it\u0026rsquo;. But if anyone acts in a proactive way, they are not sure how they going to be received, therefore there is very little will from the public servants to be proactive. (F34, Development partner)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eFrequent changes in strategic direction.\u003c/b\u003e The muted layers of decision-making and accountability contribute to the frequent changes in MOH\u0026rsquo;s strategic direction when the top leadership rotates in Fiji and Vanuatu.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eThe expectations to our department changes all the time, as the management changes, the action plan changes. (F09, Government)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eWe had a change of minister about five times while I was in MoH in that two years. Which is incredibly frustrating. [\u0026hellip;] When a new minister would come in, we'd see an overhaul of what we were doing. (V15, Government)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAlthough the data reflect that in Vanuatu department heads tend to retain a certain amount of bureaucratic autonomy.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eYou'd see some things come through, when the minister said that we need to work on this, and you're like, \u0026lsquo;Okay, but it's not in the policy, It's not in the strategy, nor is it in our business plan for this year. So do we really need to work on it now?\u0026rsquo; And it was \u0026lsquo;well, yes.\u0026rsquo; So if the things that come from below their level, they generally got a fair bit of autonomy to do what they like, but for things that come from above by the DG or the minister, they generally a bit more propelled into doing it, whether they agree with it or not. (V15, Government)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003ePublic service reforms but with similar issues in Fiji.\u003c/b\u003e The Ministry of Civil Service recognised the nuisance of the lack of autonomy that resulted from the muted layers of decision-making and accountability; it has attempted to salvage this issue through a series of public service reforms since 2016. However, participants explain that the way the reforms are planned seems to contradict their aim to give more responsibility to lower-level executives.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eIt\u0026rsquo;s part of the narrative you hear from the AG and the PM that they want to do things differently [\u0026hellip;] ultimately to achieve different results, you got to act in different way. [\u0026hellip;] I can also understand that moving from a military style government into a new government is a very different way of doing things. (F34, Development partner)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe PSs are responsible for planning and implementing such reforms in their respective ministries, and in MoH even the Deputy Secretaries and Department Directors are excluded from this planning and decision-making process [paraphrased, F08, F14].\u003c/p\u003e \u003cp\u003eIn summary, in Fiji, the centralisation of decision-making authority and the political culture leave little bureaucratic autonomy in the hands of policy makers. These findings are concerning for tobacco control because even if administrators are \u0026ldquo;public-interested\u0026rdquo;, they have little autonomy to ensure that health interests are elevated in tobacco governance. In Vanuatu, strategic priorities often change due to the frequently changing political landscape, resulting in a heavy rotation of high-level MoH officials. This is likely to disrupt the strategic elevation of health interests in intersectoral governance.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.5. Capability to analyse policy alternatives for public interest\u003c/h2\u003e \u003cp\u003eGovernment agencies are able to conduct their own analysis to determine the most beneficial policy alternatives for the public and avoid excessive reliance on the information provided by particular actors (such as tobacco industry) only if they have adequate human, technical, financial and administrative capacity. However, MoH in both Fiji and Vanuatu faces capacity issues often visible in SIDS.\u003c/p\u003e \u003cp\u003e \u003cb\u003eLimited human capacity.\u003c/b\u003e While in larger LMICs often an entire unit is responsible for tobacco control, due to small populations, in SIDS there is often one person dedicated to NCDs or tobacco control; thus, smoking is likely to receive less attention [paraphrased, F27]. In Fiji and Vanuatu, tobacco control receives limited resources. There is one government official dedicated full time to tobacco control policy making and a number of environmental health officers work on ensuring compliance; however, long-term vacancies in these positions are common. This is likely to have a detrimental effect on the agency's performance.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eWe have a very good policy environment in Vanuatu for public health. It\u0026rsquo;s just that there are limited human resources. It is difficult with the scattered islands. (V30, Government)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eLimited technical capacity.\u003c/b\u003e Acquiring the necessary technical skills in areas related to tobacco governance is challenging in Fiji and Vanuatu due to the limited higher education courses available in local universities. Thus, finding policy makers with the required skills takes time.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eThe Director of Planning just came in like less than six months ago. Prior to that, that post has been vacant for the past three to four years. (V29, Government)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eOne person has been negotiated agreements, but he now has left. So we don't have any trading negotiations now; we have no trade negotiators. (V25, Government)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eLow financial capacity.\u003c/b\u003e The low financial resources dedicated to NCDs are commonly seen as a barrier to strengthening tobacco control.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eEven though the government declared that there is an NCD crisis, not only in Vanuatu but in the whole Pacific, when it comes to sharing the funds, still communicable diseases receive more money. (V12, Government)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eIssues in performance management and accountability.\u003c/b\u003e Participants expressed their opinion that performance management and accountability issues constrain administrative capacity within the government.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eI do not think we have enough good people in the right positions in government. I think the workplace culture in Vanuatu in the government is not very conducive to having performance determine your position. Basically, people can be underperforming and it's never picked up, and it happens all the time (V25, Government)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThese findings show that SIDS vulnerabilities have a detrimental impact on health sector actors' capability to analyse policy alternatives for public interest. Although human and financial resource problems are conditions commonly observed in LMICs, the data demonstrate that in Fiji and Vanuatu such issues are aggravated by geographical isolation, the small size of the population and its economy, and the logistical and financial challenges of distributing services across several islands. This is concerning for tobacco control because when a careful analysis of the policy alternatives is not conducted, policy makers remain vulnerable to vested interests they aim to regulate.\u003c/p\u003e \u003c/div\u003e\n\u003cdiv id=\"ftn1\"\u003e\n \u003cp\u003e[1] Second-in-command in a ministry in Fiji, the equivalent of DG in Vanuatu.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis paper explored the institutional conditions that shape health sector actors\u0026rsquo; ability to protect public health interests in multisectoral tobacco governance in Fiji and Vanuatu. Our study contributes to the commercial determinants of health, health governance and development literature by shedding light on the connection between SIDS vulnerabilities, political context, and government structures, rules, and accountability in multisectoral policy development for tobacco control in Fiji and Vanuatu. Previously no similar study has been published on PSIDS that would provide a theory-informed, interdisciplinary analysis of the institutional conditions that shape the ways tobacco is governed.\u003c/p\u003e \u003cp\u003eThe 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 the political parties contributes to the politicisation of government in both states, resulting in the questionable \u0026ldquo;public-interestedness\u0026rdquo; of high-level government officials. The system of checks and balances embedded into democratic governance appears to be muted, and policy makers have limited bureaucratic autonomy to elevate health interests in multisectoral policy making amidst the frequent rotation of high-level government officials. Capacity constraints aggravated by SIDS vulnerabilities negatively impact health sector actors' capability to analyse policy alternatives.\u003c/p\u003e \u003cp\u003eThe findings show that SIDS vulnerabilities have a major impact on the ways institutions are structured and operate in both states. In Vanuatu, clientelism and patronage are consequences of the country being scattered over multiple little islands, and due to the weak regulation of political parties, the political landscape rapidly changes in the country. As a result, individuals in executive government positions do not necessarily govern for public interest but their personal, political, or localised interests. Fiji, being a post-authoritarian state, has a centralised government system where the ministries are highly dependent on the AG's discretion, and since he tends to prioritise commercial interests, this constrains MoH from elevating health interests in tobacco governance. These political conditions negatively impact the performance management and accountability mechanisms of these countries, which are further burdened by the weak human and financial capacities common in SIDS. The consequences are twofold. Firstly, the rules of policy making \u0026ndash; which could ensure the protection of public health interests \u0026ndash; are often not followed, and there are no terms of engagement implemented with the tobacco industry. Secondly, health sector actors have limited capacity and capability to make well-informed policy choices.\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e4.1. Contribution to the literature\u003c/h2\u003e \u003cp\u003eOur findings confirm a previous study reporting that SIDS vulnerabilities make these countries susceptible to the influence of vested interests (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). This makes the careful examination of policy alternatives in multisectoral tobacco policies challenging. Consequently, government agencies are likely to rely on the readily available information provided by the tobacco industry or development partners. Prior research in tobacco control in PSIDS reported on the detrimental impact of capacity issues on policy making and implementation (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e). Other studies focusing on food policy in PSIDS had similar results; they showed that limited human and financial capacity is a major barrier to the development of multisectoral food policies (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan additionalcitationids=\"CR63\" citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e). Our study provides new depth to these insights by analysing how SIDS capacity constraints limit health sector actors' capability to implement and participate in policy and legislative processes that could ensure a level playing field if adequately employed.\u003c/p\u003e \u003cp\u003eThe governance and development literature (\u003cspan additionalcitationids=\"CR66 CR67 CR68 CR69 CR70 CR71 CR72\" citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e) has recognised that LMICs often establish democratic institutions as the means to become more legitimate for the public and development partners, while in reality the way the country is governed relies on old, informal mechanisms, usually dominated by a political elite. Levitsky and Murillo (\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e) call this parchment reforms, when \u0026ldquo;\u003cem\u003erules exist on parchment, but in practice, they do little to constrain actors or shape their expectations\u003c/em\u003e\u0026rdquo;. Pritchett et al. (\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e) describe this as \u003cem\u003e\"isomorphic mimicry, wherein the outward forms (appearances, structures) of functional states and organisations elsewhere are adopted to camouflage a persistent lack of function.\"\u003c/em\u003e This could help understand why there is a gap between the rules and reality of policy making in Fiji and Vanuatu; however, our study has expanded this understanding by explaining that it is not mere political calculations that are behind such fa\u0026ccedil;ade but a complex interplay of SIDS vulnerabilities.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e4.2. Implications for policy\u003c/h2\u003e \u003cp\u003e \u003cb\u003eStrengthening human, technical and financial capacity.\u003c/b\u003e Multiple development partners work together with the governments of Fiji and Vanuatu to build human, technical and financial capacity, including strengthening tobacco control. However, as the data revealed, NCD prevention receives less financial assistance than other areas of health and do not target civil society. Funding CSOs to operate in this field in PSIDS would be an important step in strengthening health sector actors\u0026rsquo; capacity to protect public health interests. Increasing the human, technical and financial capacity of MoH would support well-informed policy choices; it would provide adequate capacity to meaningfully follow the policy process, implement terms of engagement, and present more evidence on the harmful impact of supporting the tobacco industry. However, capacity building efforts must be sensitive to the cultural context of PSIDS (\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e). These insights are aligned with prior suggestions to build capacity in PSIDS to strengthen tobacco control (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e). However, our findings imply that capacity building is unlikely to bring the desired outcomes without strengthening governance.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStrengthening performance management and accountability mechanisms.\u003c/b\u003e Our study suggests that performance management and accountability mechanisms need to be strengthened via governance strengthening programmes such as those often provided by development partners. This would ensure that the carefully planned policy processes are followed, and it would improve the implementation of FCTC, which could result in the development of terms of engagement with the tobacco industry. This recommendation is aligned with CDoH scholars\u0026rsquo; suggestions (\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e, \u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e), highlighting the need for robust accountability mechanisms to regulate harmful commodity industries; moreover, it corresponds to development scholars\u0026rsquo; works (\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e), emphasising that government strengthening is essential to address the gap between the rules of policy making and their implementation. Governance strengthening initiatives are frequently provided by development partners to LMICs, and there have been examples of such programmes in Fiji according to the collected data; however, the political elite has been selective on which recommendations of the development partners to follow, which leads to the next insight of this study.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStrengthening the rules of the political system.\u003c/b\u003e While this research mainly focused on governance in Fiji and Vanuatu around tobacco, the results suggest the need to strengthen the political system's regulation. The tightening of the regulation of the political parties and strengthening the Parliament is necessary for PSIDS for the institutional conditions to ensure the protection of public interests. In both Fiji and Vanuatu, Parliamentary capacity needs to be improved to enable oversight over the government to facilitate public-interested policy making and that the governance strengthening programmes bring the desired results. In Vanuatu, regulation of the political parties must be strengthened to decrease clientelism, patronage, and frequent rotation among high-level government officials. In Fiji, the transition to full democracy should be encouraged: the political elite needs to be persuaded to let go of its control \u0026ndash; the data showed that there had been relevant developments; thus, a complete transition to democracy is undoubtedly on the cards for Fiji.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e4.3. Limitations\u003c/h2\u003e \u003cp\u003eThis study was constrained by the funding and time restrictions of being a doctoral project. This resulted in several limitations. First, we have not had the resources to formally include local Fijian or ni-Vanuatu researchers. This limitation was mitigated by successfully requesting substantial guidance from government officials in MoH in Fiji and Vanuatu. Second, only two case studies were included in our study. This has a detrimental impact on the generalisability of the findings but allows the exploration of the institutional conditions shaping health sector actors\u0026rsquo; capability to protect health interests in tobacco governance.\u003c/p\u003e \u003c/div\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003eHealth 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. Changing the institutional conditions is a slow and lengthy process, but initiatives focusing on some relevant areas are already underway in Fiji and Vanuatu.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate: Research Ethics approval was granted for this study by the Fiji National Health Research and Ethics Review Committee, the Vanuatu Cultural Centre, and the Australian National University Human Research Ethics Committee (protocol number: 2017/945). Written informed consent was received from all participants to be involved in the study as per the approved Ethics protocol. The Ministry of Health and Medical Services of Fiji and the Ministry of Health of Vanuatu endorsed this study.\u003c/p\u003e\n\u003cp\u003eConsent for publication: Not applicable.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests:\u0026nbsp;The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding: The Australian National University provided funding for Dori Patay to undertake this doctorate research under its University Research Scholarship, The Australian National University Higher Degree by Research Fee Remission Merit Scholarship, The Australian National University Vice Chancellor\u0026rsquo;s Travel Grant schemes. Grant number is not applicable.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions: DP: Conceptualisation; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Validation; Visualisation; Roles/Writing - original draft. SF:\u0026nbsp;Supervision; Writing - review \u0026amp; editing. AS: Supervision; Writing - review \u0026amp; editing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgements: We thank the Dr Dip Chand and the late Dr Isimeli Tukana of the Ministry of Health and Medical Services of Fiji, and Dr Len Tarivonda of the Ministry of Health of Vanuatu for their guidance on this project.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGlobal Burden of Disease Collaborators. 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Fairfield, Vic: Inkshed Press Pty Ltd; 2014.\u003c/li\u003e\n\u003cli\u003eMagnusson R, Patterson D. Global action, but national results: strengthening pathways towards better health outcomes for non-communicable diseases. Critical Public Health. 2019:1-13.\u003c/li\u003e\n\u003cli\u003eSwinburn B, Kraak V, Rutter H, Vandevijvere S, Lobstein T, Sacks G, et al. Strengthening of accountability systems to create healthy food environments and reduce global obesity. The Lancet. 2015;385(9986):2534-45.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"globalization-and-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"glah","sideBox":"Learn more about [Globalization and Health](https://globalizationandhealth.biomedcentral.com/)","snPcode":"12992","submissionUrl":"https://submission.nature.com/new-submission/12992/3","title":"Globalization and Health","twitterHandle":"@GHJournal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"small island developing states, Pacific, commercial determinants of health, noncommunicable diseases, multisectoral policy, multisectoral governance, whole-of-government, tobacco control, Fiji, Vanuatu","lastPublishedDoi":"10.21203/rs.3.rs-2164081/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2164081/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe 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 \u0026ndash; often called SIDS vulnerabilities \u0026ndash; that set them apart from other LMICs. This study aims to explore the institutional conditions that shape health sector actors\u0026rsquo; capability to protect public health interests in multisectoral governance, focusing on tobacco control in Fiji and Vanuatu.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe 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.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe 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\u0026rsquo; questionable \u0026ldquo;public-interestedness\u0026rdquo;. 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\u0026rsquo; frequent rotation. Finally, capacity constraints aggravated by SIDS vulnerabilities negatively impact health sector actors' capability to analyse policy alternatives.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eHealth 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.\u003c/p\u003e","manuscriptTitle":"The challenges in protecting public health interests in multisectoral governance in the context of small island developing states. 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