The SA government aims to reduce premature mortality (under 60 years of age) from NCDs through its strategic plan for NCDs (24). In order to do this, the combination of policies, programs and supportive environments are targeted to reduce the risk factors for hypertension and diabetes, in line with the WHO best buys (14). The findings of this qualitative study show the enablers and challenges for the planning of targeted population-level interventions. Partnerships, multisectoral approaches, community engagement and empowerment, responsive contextualized policies developed using a strategic framework, supportive enabling environments, and ongoing monitoring and evaluation to inform policy, and programme planning were common enablers. Conversely, the challenges found were lack of time and resources, lack of consultation and stakeholder consultation, regulations and competing priorities, and ineffective monitoring and evaluation systems.
The SA National Policy Development Framework (NPDF) (25), sets clear principles for effective policy development, emphasizing that it must be contextualized and responsive to people needs, and the public must be encouraged to participate. When the correct procedure for public comment and input is not followed in the planning phase, the policies not only run the risk of not being delivered in a contextually relevant way but may also be rejected by the public (23, 27, 28). Non-reliance on the bottom-up approach can have serious consequences on the time taken to move from policy formulation to implementation (26). Naude and colleagues (27) found that policy making processes are often lengthy and complex, and often include back-and-forth consultations with many diverse stakeholder groups. Most participants expressed some challenges related to formulation of supportive polices, there was a consensus that there is a room of improvement for formulation of certain supportive policies where thorough engagement with stakeholders could take place (28). These policies include the national strategic plan for prevention of NCDs (2020–2025), the policy on salt reduction, excises taxes on sugar and sweeten beverages as well as smoking. Although, there is no definitive list of what sectors should be involved in collaborative planning, the core partnerships include those across government, civil society, and community members, as well as between different levels and departments in government (29, 30).
Formulations of policies and the planning of programs are largely reliant on monitoring and evaluation data as prescribed in the National Policy Development Framework (25). This study found that most evaluation data was unreliable and did not support the strategic development of policies. Lack of baseline data and not using evidence for policy making creates opportunities for the competing priorities of stakeholders (31), which can have detrimental effects on the formulation of policies and programmes (32, 33). This can lead to unethical sponsorship and unregulated advertising of unhealthy foods (34). The socio-economic status of low-income communities create ideal targets for large corporations to sponsor programs with unhealthy food and beverages, when other sponsorships are not as available – and government departments become reliant on these corporations when planning. There is a wealth of public health research which indicates that food promotion has a direct effect on peoples behaviours related to food and beverages (35). The main drivers of planning for programs and policies were the current contextual realities, costs, logistics, and people (clinicians, NGOs, funders) (27). Collaborative planning and engagement (29), the re-evaluation of the aims and priorities of policies and programs, and reliable evaluation data are essential in order to successfully plan and formulate policies and programmes to reduce the risk factors for hypertension and diabetes at a population level.
Strengths and limitations
This study was conducted by trained qualitative researchers familiar with policy analysis. Coding and analysis were conducted in duplicate. This study presents the perceptions of policy makers and civil society representatives regarding their perceptions and experiences on implementation of population level interventions targeting risk factors of diabetes and hypertension in SA. Due to the COVID-19 pandemic we were unable to conduct the interviews face to face and therefore our experiences of the interviews may have missed non-verbal cues. Participants were willing to engage, and we were concerned that they may be protective of their relevant departments or places of work. Participants felt comfortable to speak freely after signing the consent forms and we continued to reassure participants of their rights within the study, throughout the data collection. Additionally, we used member checking to verify with participants our synthesis of their data. We cannot determine whether saturation on enabling environments was not reached, as the time to explore the relevant data was minimal as compared to policies and programs, due to the overwhelming demands of these structures on COVID-19 responses and access to reliable connectivity, especially for NGOs. However, adopting ethical research practices, as well as using COREQ reporting guideline, we present the study transparently.