STRATEGIES FOR ACCELERATED IMPLEMENTATION

OF THE TOBACCO CONTROL TREATY:

LESSONS FROM KEY GLOBAL HEALTH IN IT IAT IVES

Shoba John

Dr. K . Sr ina th Reddy

Dr. Pete r P io t

ALL I ANCEFRAMEWORK CONVENT ION

Shoba John1 K. Srinath Reddy2 & Peter Piot3.

Strategies for Accelerated Implementation of the Tobacco Control Treaty: Lessons from Key Global Health Initiatives.

Framework Convention Alliance, October 2013.

Corresponding author: Shoba John. Email: johns@fctc.org

DISCLAIMER: This research aimed to examine initiatives that attracted political commitment and resources to various public health concerns over the last two decades. The research does not endorse the initiatives discussed in the pa-per, nor critique their merits or otherwise. The researchers and the Framework Convention Alliance intend to highlight key strategies that enabled key global health initiatives to galvanise resources, with a view to inform governments and the donor community of their relevance to tobacco control.

1 Framework Convention Alliance 2 Public Health Foundation of India3 London School of Hygiene & Tropical Medicine

TABLE OF CONTENTS

Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

I . Rat iona le . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

I I . Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

I I I . Scope & L im i ta t i ons o f the Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

IV. Fac to rs tha t Sparked G loba l In te res t in Key Pub l i c Hea l th Conce rns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

V. St ra teg ies Engaged by Key Pub l i c Hea l th Conce rns to Ga lvan ise

Po l i t i ca l Momentum And Pub l i c Fund ing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1

V. 1 The Case of H IV/A IDS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1

V.2 the Case of Ma la r ia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

V.3. The Case of Tubercu los is . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

V.4 The Case of Mate rna l and Ch i l d Hea l th . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

V.5 The Case of Vacc ina t ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 7

V I . Resource Mob i l i sa t i on St ra teg ies : Lessons From Key Hea l th Conce rns

Fo r Tobacco Cont ro l . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

V I . 1 Demonst ra t ing Ev idence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

V I .2 Messag ing And Commun ica t ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

V I .3 Spearhead ing Commi tments Th rough Leadersh ip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

V I .4 Synerg is ing Wi th Ex is t ing Hea l th And Deve lopment Pr io r i t i es . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

V I .5 L ink ing Wi th Emerg ing Hea l th And Susta inab le Deve lopment Frameworks . . . . . . . . . . . . . . . . . . . 2 1

V I .6 L i t i ga t i on . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 1

V I .7 Suppor t ing C iv i l Soc ie ty Act ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

V I I . Recommendat ions To The FCTC Confe rence Of The Par t i es . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

V I I . 1 I dent i fy Bar r i e rs To Treaty Imp lementa t ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

V I I .2 Deve lop G loba l St ra tegy, Costed P lans & Mode l Retu rns On Investment . . . . . . . . . . . . . . . . . . . 23

V I I .3 Bu i l d A Po l i t i ca l St ra tegy To Enhance Commi tment To Tobacco Cont ro l . . . . . . . . . . . . . . . . . . . . . 23

V I I .4 Ut i l i se The NCDs and Deve lopment Frameworks to Advance FCTC Imp lementa t ion 23

VI I .5 FCTC Countdown 2025—Acce le ra te Treaty Imp lementa t ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

V I I .6 Rebrand And Deve lop A Commun ica t ions St ra tegy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

V I I .7 Mob i l i se Domest i c And In te rna t iona l Commi tments And Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

V I I .8 Fo rge A l l i ances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

V I I I . Conc lus ion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Refe rences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

44

ACKNOWLEDGEMENTS

The authors wish to acknowledge the referrals to relevant published literature and introductions to key informants. The key informants brought the wealth of their expertise in health and development financing to augment published literature. Copyright permissions granted to reproduce published information from various organisations is very much appreciated. There has been incredible support from the FCA team from research to review, editing and production. Financial support from ASH International has made this research possible.

KEY INFORMANTS

Dr. Lucica Ditiu, Stop TB Partnership

Dr. Sarah England, Global Health Team, Bloomberg Philanthropies

Dr. Rachel Nugent, Department of Global Health, University of Washington

Mr. Thomas Bollyky, Council on Foreign Relations

Dr. Nevin Wilson, International Union Against Tuberculosis & Lung Diseases

Mr. Douglas Webb, HIV, Health and Development Group, United Nations Development Programme

Prof. Don de Savigny, Swiss Tropical and Public Health Institute

5

ACRONYMS

AIDS Acquired Immunodeficiency Syndrome

CCM Country Coordinating Mechanism

COP Conference of the Parties

CGD Center for Global Development

DAH Development Assistance for Health

FCTC Framework Convention on Tobacco Control

GAVI Global Alliance for Vaccines and Immunisation

Global Fund Global Fund to Fight AIDS, Tuberculosis and Malaria

HIV Human Immunodeficiency Virus

IUATLD International Union Against Tuberculosis and Lung Disease (the Union)

LMICs Low and Middle Income countries

MCH Maternal and Child Health

MDGs Millennium Development Goals

NCDs Non-Communicable Diseases

NGOs Non-Governmental Organisations

PEPFAR President’s Emergency Plan For AIDS Relief

RBM Roll Back Malaria

STP Stop TB Partnership

TB Tuberculosis

UN United Nations

UNAIDS Joint United Nations Programme on HIV/AIDS

UNICEF The United Nations Children’s Fund

WHO World Health Organization

WTO World Trade Organization

66

LIST OF BOXES, F IGURES AND TABLES

BOXES

RBM’s Advocacy successes over the years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Improv ing messages about the tobacco ep idemic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Ma la r ia Advocacy Work ing Group—Lessons fo r tobacco cont ro l . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Tobacco Tax Campa ign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

F IGURES

F igu re 1 . Number o f peop le l i v ing w i th H IV, 1990-2008 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

F igu re 2 . Retu rn on Investment o f one US Do l la r . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

F igu re 3. Overv iew of to ta l commi tments p ledged by stakeho lde rs

du r ing the MDG Summi t , New York , September 20 10 (b i l l i ons o f US do l la rs ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

F igu re 4 . US government A IDS commun ica t ion p romot ing qu i t t i ng . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

F igu re 5. Per-cap i ta pub l i c spend ing on tobacco cont ro l and pe r cap i ta revenues

co l l ec ted th rough tobacco taxes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

TABLES

Tab le 1 . Deve lopment Ass is tance fo r Hea l th by Catego ry, 2004 - 2008, in 2008US$ . . . . . . . . . 8

Tab le 2 . Est imated cont r i bu t i ons to ma la r ia cont ro l ac t iv i t i es by deve lopment agenc ies . . . . . . . . . 12

7

I . RAT IONALE

Globally, tobacco kills nearly 6 million people every year. The World Health Organization (WHO) proj-ects that, if unchecked, the human toll will rise to more than 8 million deaths annually by 2030. Eighty percent of these deaths are predicted to occur in low and middle-income countries1. By the end of the century, the number of tobacco-related deaths will reach 1 billion2.

Member States of the WHO responded to this health emergency in 1998 by starting negotiations on a treaty to address the growing tobacco epi-demic. The resultant Framework Convention on Tobacco Control (FCTC) was adopted in May 2003. Since then, 176 countries and the European Union have ratified it to become Parties* to the treaty. As the international, legally binding agreement on tobacco control, the FCTC represents the global consensus regarding the road map to curb the tobacco epidemic.

2013 marks a decade since the adoption of the treaty. Several governments have begun to take measures to implement the treaty; however treaty implementation has yet to gain momentum and become sustainable so as to reduce harm from tobacco. Ninety percent of the world’s popula-tion remained unprotected from tobacco industry marketing, 92 percent live in countries where taxes represented less than 75 percent of the retail cigarette price, and 84 percent of WHO Member States reported a lack of high-level implementa-tion of smoke-free policies at the national level3. FCTC Parties report that they face diverse barriers to effective and sustainable implementation of the treaty4.

At the World Health Assembly in 2012, WHO Member States agreed to a 25 percent reduction in NCD-related premature deaths by 20255. Achiev-ing this target requires drastic reduction in tobacco use, a major risk factor for NCDs, through rigorous tobacco control—among other interventions—in less than 12 years.

* WHO Member States that have signed, ratified/ac-ceded to the treaty.

Further, the World Health Assembly in May 2013 adopted a target of 30 percent relative reduction in the prevalence of current tobacco use in persons aged 15+ years, under the NCD Global Monitoring Framework6. This desirable but ambitious target calls for significant scaling-up of efforts to imple-ment the treaty, which in turn requires resources of various nature, particularly for low-income coun-tries.

The budget of the FCTC Conference of the Par-ties (COP) largely supports treaty-related meetings, some technical work and operational costs. Actual treaty implementation by countries that are FCTC Parties is grossly under resourced, technically and financially. As per the WHO Report on the Global Tobacco Epidemic 2011, governments spend less than US$1 billion on tobacco control annually7. It is therefore important that the next session of the COP seriously addresses resource constraints for FCTC implementation among its Parties.

The fifth session of the COP (COP5) set up the Working Group on Sustainable Measures to Strengthen Implementation of the WHO FCTC. This working group represents an opportunity and plat-form for governments to examine the barriers to accessing resources, explore means to overcome them, and provide strong recommendations to COP6 in 2014. Tobacco is a development concern, in addition to its health implications. The discus-sions around the Sustainable Development Goals at the United Nations present one international opportunity, among others, to position tobacco control for global attention.

Even as tobacco control continues to be under-funded, Development Assistance for Health (DAH) grew from US$5.6 billion in 1990 to US$21.8 billion in 2007, in real terms8. Several public health chal-lenges that were under-funded until the 1990s reportedly began to receive development aid across this period. For example, HIV/AIDS received US$7.86 billion from donor governments in 20129. However, as Table 1 indicates, development as-sistance for NCDs, of which tobacco use is a major risk factor, constituted just 2.9 percent of the DAH in 200810.

STRATEGIES FOR ACCELERATED IMPLEMENTATION OF

THE TOBACCO CONTROL TREATY:

LESSONS FROM KEY GLOBAL HEALTH INIT IATIVES

88

This research examined initiatives that attracted political commitment and resources to various public health concerns in the two decades since 1990. It aimed to highlight strategies that enabled these initiatives to galvanise resources, with a view to informing governments and the donor community of their relevance to tobacco control.

Tab le 1 . Deve lopment Ass istance fo r Hea l th by Category, 2004 - 2008, in 2008US$

2004 2005 2006 2007 2008HIV/AIDS, Malaria, TB

3,267 4,315 5,291 6,546 8,182

MCH 1,845 2,262 1,999 2,959 3,170

Health Sector Sup-port

209 404 818 929 1,000

Unallocable* 2,805 3,132 3,303 3,736 4,721

NCDs, CGD 243 408 434 514 700

Other 6,224 6,070 6,123 5,944 6,408

TOTAL DAH** 14,593 16,590 17,969 20,628 24,181

%NCD of total DAH 1.67% 2.46% 2.42% 2.49% 2.90%

Source: Centre for Global Development (CGD), 2010. (Updated table, obtained from author). Note that these figures are still not completely comparable as only the NCDs category includes for-profit private sector health as-sistance. NCDs funding as a percent of overall DAH would be smaller if all for-profit private funding were included in the other categories. *Adjusted to exclude estimated NCDs funding; ** Years 2004-2008 augmented by authors’ NCDs totals

I I . METHODS

The research aimed to:

` Identify the stimuli that triggered political inter-est in key global health concerns over the last two decades

` Describe strategies that helped these health initiatives gain political support and resources

` Examine the lessons from these initiatives for tobacco control

` Develop recommendations for the COP to en-hance political support and resources for FCTC implementation.

This is a qualitative, process-tracking, desk re-search. Published literature informing the research objectives was identified and analysed on the basis of the research questions. Gaps in information were addressed through selected key informant interviews of experts in health and development financing.

Public health concerns that challenged the world and managed to mobilise political commitment in the last two decades were drawn into the research. The availability of published work examining the processes and strategies that propelled these

initiatives was a key determinant in the choice of health concerns for the research. Transferability of lessons to tobacco control was another key cri-terion for the choice of issues. Initiatives on AIDS, malaria, tuberculosis (TB), maternal and child health (MCH) and vaccination were tracked in this research.

The key informants were identified based on their expertise in health or development financing. Representatives of organisations that have mo-bilised resources for key public health concerns were also included in the interviews. Availability of the informants during the data collection phase of the research also determined their inclusion in the interviews.

The information gathered through literature review and key informant interviews was analysed against the research questions.

9

I I I . SCOPE & L IMITATIONS OF

THE RESEARCH

The research presents major stimuli that triggered interest in some of the major public health con-cerns of the last two decades, and describes the strategies that were reported as contributing most to the growth in political commitment and resourc-es for these concerns.

The research does not aim to provide an econo-metric analysis of the outcomes or efficacy of these strategies in determining the outcomes of the initiatives. It does not cover health challenges that were not comparable in magnitude or nature to the tobacco epidemic. Non-health concerns that might have gained traction in recent decades were not explored. While the research intended to examine both domestic and international resources for the public health concerns discussed, paucity of data on country budgets limited the results to focus largely on reported international resources.

The results of this research reveal the need for more in-depth quantitative analysis of available resources for tobacco control, including in-country resource allocations. It would also be meaningful to explore and contrast this against non-health chal-lenges that gained political attention in the same timeframe.

IV. FACTORS THAT SPARKED

GLOBAL INTEREST IN KEY

PUBLIC HEALTH CONCERNS

Analysis of the histories of the researched public health initiatives reveals events or scenarios that sparked political interest in the issues. The major stimuli for action on these concerns are discussed below.

Rising human toll: With the exception of AIDS, the public health concerns that this research explored have existed over a considerable period of human history. Some of these concerns, such as TB and malaria, date back to ancient times11,12. Others, such as maternal and child health (MCH), became more prominent in recent decades.

All the researched global public health concerns had reached epidemic proportions by the mid-1990s, with low and middle-income countries (LMICs) bearing the bulk of the burden. 2.5 million people died of TB in 1990. It was estimated that if treatment availability did not improve, another 1 million people would die within the decade. Annual new cases of TB were predicted to increase from 7.5 million in 1990 to 10.2 million by the end of the decade13. Reported malaria deaths in the endemic countries more than doubled in the decade be-tween 1990 and 2003. While Europe reported declining deaths, the death toll in Africa indicated an alarming increase during this period14.

F igure 1 . Number of peop le l iv ing wi th HIV, 1990-2008

0

5

10

15

20

25

30

35

0 5 10 15 20 25 30

Tuberculosis:Case Finding & Treatment

Heart Attacks:Acute Low Cost Management

Expanded Immunization

Malaria:Prevention & Treatment

HIV:Combination Prevention

Local Surgical Capacity

Ratio

Num

ber

of

peo

ple

(mill

ions

)

Year

17.3

8.66.0 5.0

2.3 1.0 0.03

40.3

TotalHealth careprofessionalassociations

Businesscommunity

Globalphilan-thropic

institutions

UN & othermulti-lateral

organizations

Civilsociety

49lowest income

countries

Allcountriesexcept

49 lowest income

High-income Middle-income Low-income

17.60 0.013

167.57

1.36

5.43 0.001

US

$ p

er c

apita

Per capita total tax revenue from tobacco products

Per capita public spending on tobacco control

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

Source: Modified from WHO/UNAIDS/UN The Millennium Development Goals Report, 2009.

1010

As Figure 1 indicates, there was a dramatic surge in the HIV/AIDS epidemic between 1990 and 2000, and beyond. During the decade, the number of people living with HIV infection increased from 7.6 million to 28.3 million. The number of deaths from AIDS also indicated a rising trend during this period15.

Emergence of cost-effective interventions: Several of the infectious diseases witnessed low-cost innovations in areas of diagnosis, treatment and technologies in the 1990s. For instance, insecticidal bed nets emerged as a cost-effective malaria prevention technology during this period. The drug therapy and diagnostic tools for TB control also became available. Vaccines, vitamin A supplementation and post-partum care offered scope for improved maternal and child survival. In the case of HIV treatment, the price of antiretroviral drugs decreased by well over 90 percent, even while they were under patent16. The emergence of cost-effective inventions and interventions that could reach populations at risk for these diseases, and the prospect of eradicating some diseases such as polio, presented an appealing scenario for donors.

Response delays: By the mid 1990s, cost-effective preventive and treatment options were known and widely available in developed countries for several of the infectious diseases, such as HIV/AIDS. But these were not universally available in poorer countries. The growing gap between the demand and the supply of drugs, technologies, services and prevention strategies worsened these epidemics and created distress in the developing world. In the case of AIDS, the acute crisis in ac-cess to treatment in the developing world was the stimulus that led to protests disrupting international AIDS conferences and meetings of the World Trade Organization (WTO). These protests in turn cata-lysed political discussions on the prevention and control of HIV/AIDS among world leaders17.

Donor interest: Maternal and child health chal-lenges have existed for centuries. However, per-sonal conviction and the commitment of resources by influential philanthropists, in particular Bill and Melinda Gates, re-vitalised the global immunisation drive against major infectious diseases that affect women and children, including cervical cancer and measles. The Gates Foundation’s pledge of US$750 million in 1998 triggered commitments

IT ’S T IME TO RESOURCE TOBACCO CONTROL

The f i rs t th ree t r iggers that st imu lated act ion on in fect ious d iseases

ho ld t rue fo r tobacco cont ro l . The g loba l tobacco ep idemic is stead i ly

growing and rap id ly expand ing in LMICs , wh ich are increas ing ly be ing

targeted by the tobacco indust ry. Ev idence-based , cost-ef fect ive

in te rvent ions and an in te rnat iona l t reaty on tobacco cont ro l do ex ist .

Never the less , there has been t remendous de lay in respond ing to the

ep idemic at count ry and g loba l leve ls , wh ich is tak ing a monumenta l

to l l on human l ives and economic deve lopment . Ph i lanthrop ies such

as the Bloomberg In i t ia t ive and Gates Foundat ion and count r ies l ike

Aust ra l ia and the European Un ion have made recent investments

in FCTC imp lementat ion. There is an urgent need to bu i ld on th is

momentum and st imu late po l i t i ca l and donor in te rest now to save

l ives and economies.

11

from several other donors, and led to the formation of the Global Alliance for Vaccines and Immunisa-tion (GAVI)18. Similarly, the US Government’s con-tribution of US$44 billion to fight HIV/AIDS through the President’s Emergency Plan For AIDS Relief (PEPFAR) since 2003, and Canada’s more recent contribution of US$2.85 billion to improve MCH through the Muskoka Initiative, have helped mobil-ise further resources for these challenges19.

V. STRATEGIES ENGAGED

BY KEY PUBLIC HEALTH

CONCERNS TO GALVANISE

POLIT ICAL MOMENTUM AND

PUBLIC FUNDING

An analysis of the health concerns studied reveals that their advocates employed several strategies to garner political support and resources. The key strategies that worked for each of the concerns are discussed in detail below.

V.1 THE CASE OF H IV/A IDS

2.8 million people died of AIDS in 1999, by which time it had become the leading cause of death in Africa20. Political support for global action on AIDS began to gather momentum in the mid-1990s. A variety of strategies came together over the last two decades to attract attention and resources to the disease. A dedicated funding stream was created in 2002, which dramatically increased resources for the fight against AIDS, as well as tuberculosis and malaria21.

Positioning the crisis in access to HIV drugs as a global cause: The AIDS move-ment leveraged the crisis in access to HIV treat-ment, which struck several low-income countries in the mid-1990s, to make the case for an urgent global response, including resources, to address the challenge. The movement called on the world community to address the inequalities in acces-sibility and affordability of antiretroviral treatment between high and low-income countries. It was also able to showcase the consequences for the global community of inaction: several studies demonstrated the potential trans-national fallouts of AIDS-related deaths, in terms of demographic changes, poverty, productivity and national security beyond the affected countries, making a compel-ling case for a global response to the epidemic22.

Civil society activism and North-South collaboration: Street protests in several high and low-income countries, including the US, South Africa and Brazil, coupled with civil society activism

at key international events, from the Seattle WTO Ministerial Meeting (1994) to the International AIDS Conference in Durban (2000), drew global attention to the barriers to access to treatment in LMICs23. Efforts to improve access for antiretroviral treat-ment in the US were led by interest groups such as the gay-rights movement. Campaigners in the US and Europe collaborated with those in countries like South Africa to highlight the vulnerability of LMICs in this regard24. Such cooperation helped to situate AIDS as a global political concern travers-ing national boundaries, and thus garnered global solidarity.

Litigation: Simultaneous litigation in several LMICs over drug patenting that prevented afford-able access to HIV treatment helped stimulate the health versus wealth debate nationally and glob-ally. Thirty-nine pharmaceutical companies sued South Africa in 1998 to stop importing affordable generic AIDS drugs. The high-profile litigation, which pitched the pharmaceuticals against former South African President Nelson Mandela, triggered international outrage, and in turn forced the case to be eventually dropped in 2001. Around the same time, the US Government launched a complaint at the WTO against Brazil’s compulsory license provi-sions, which the latter used to decreases prices for HIV drugs. The dispute was settled through nego-tiations without a WTO ruling25. In South Africa, the Treatment Action Campaign took a rights-based approach to successfully sue the government to enforce programmes to prevent mother to child transmission of HIV, and to provide access to anti-retroviral therapy26.

Champions: World leaders have often played a catalytic role in propelling health initiatives in their nascent stages to the global platform. The AIDS movement, for instance, has seen a host of champions across sectors, which contributed to its international scope. Among country leaders, former Brazilian President Fernando Enrique Cardoso’s leadership ensured the early introduction of antiret-roviral therapy in Brazil27, while Nigerian President Olusegun Obasanjo hosted a special summit of the then Organisation of African Unity, now the African Union28.

Former UN Secretary-General Kofi Annan brought the force of his office to galvanise funding for AIDS and create the Global Fund to fight AIDS, Tubercu-losis and Malaria (the Global Fund). Mr. Annan out-lined a strategy for AIDS control and called for the creation of a global fund to address the epidemic29. Several music, sports and movie personalities also lent their support to the cause.

1212

Multi-sectoral coordination and dedicated institutions: The health, socio-economic and security concerns around AIDS called for a multi-sectoral response. The Joint United Nations Programme on HIV/AIDS (UNAIDS) brought together 11 institutions from the UN system to address the crisis. It was guided by the 2001 UN General Assembly road map, “Declaration of Commitment against HIV/AIDS”, and promotes an investment framework to control the AIDS epidemic. A similar multi-sectoral approach at the country level, such as the Country Coordinating Mechanism for HIV/AIDS, facilitates local ownership and participatory decision-making30. The Global Fund was created in 2002 to promote partnerships between governments, civil society, the private sector and communities living with the diseases.

Utilising global frameworks and institutions: The AIDS movement seized the opportunity of the United Nations Millennium Summit in 2000 to secure a disease-specific goal and targets in the Millennium Development Goals (MDGs). Goal 6 of the MDGs aims to achieve universal access to treatment for HIV by 2010, and to have halted and begun to reverse the spread of HIV by 201531. Further, the UN General Assembly Special Session on HIV/AIDS provided a global response to the crisis through its Declaration of Commitment on HIV/AIDS. The Declaration sets out national targets and global actions to reverse the epidemic, and requires periodic reporting. It also called for the creation of the Global Fund, which was launched in 200232.

Tab le 2 . Est imated cont r ibut ions to malar ia cont ro l act iv i t ies by deve lopment

agenc ies

Fiscal year Total contributions (in thousands of USD)1999 19,129,701 (1%)

2000 42,287,888 (2%)

2001 386,285,841 (21%)

2002 418,551,580 (22%)

2003 409,595,904 (22%)

2004 (Projected) 599,416,847 (32%)

Total 1,875,267,761 (100%)

Source: HLSP Institute, 2005.

V.2 THE CASE OF MALARIA

The World Health Assembly launched the Global Malaria Eradication campaign in 1955. The pro-gramme freed from malaria 37 of the 143 coun-tries that were endemic in 1950, most in Europe and the Americas. However, the programme was aborted, as time-limited eradication was consid-ered impractical in certain other countries. There-after, malaria received limited global attention until the mid-1990s33.

A global ministerial conference convened by the WHO endorsed the Global Malaria Control Strategy in 1992. However, it is the establishment of the Roll Back Malaria (RBM) partnership and funding from the Global Fund and Gates Foundation that gener-ated unprecedented public and political momen-tum towards malaria control. These initiatives led to increased funding, programs, technology, ad-vocacy and impact. As Table 2 shows, combined global spending on malaria control between 1999 and 2004 was estimated to be US$1.9 billion, with allocations growing steadily during this period34. According to the Bill & Melinda Gates Foundation, malaria deaths have dropped by 20 percent since 2000, and more than one million lives have been saved in the past decade35. The key strategies that generated this progress are briefly discussed below.

Riding the HIV/AIDS wave: Global advo-cacy on behalf of AIDS, and the response to it, spurred efforts to galvanise similar support for other major infectious diseases that had been largely ignored by the global community. The malaria cam-paign strategically used the opportunity to demon-strate the disparity in funding support that contin-ued to exist for malaria, a similar infectious disease for which cost-effective interventions existed. While

13

AIDS spurred the creation of the Global Fund, malaria benefitted greatly from it. The Global Fund has approved US$8.8 billion for malaria since 2002, and supported malaria programs in 97 countries36.

Partnership and multi-sectoral model: Even as discussions on the MDGs were gaining momentum, The Roll Back Malaria partnership was formed in 1998 to revitalise and coordinate the fight against malaria. It brought together a broad range of stakeholders, including malaria-endemic coun-tries, development partners, non-governmental organisations (NGOs) and research and academic institutions. RBM advocated successfully dur-ing the MDGs discussion phase for the inclusion of malaria in the MDGs. Its advocacy has led to increasing investment for malaria interventions from the Global Fund and other donors37.

Inclusion in the MDGs: Discussions around goals pertaining to infectious diseases began with AIDS. However, there were concerns that such a goal would reach only a narrow affected population.

RBM’S ADVOCACY SUCCESSES OVER THE YEARS

Nov. 1998 RBM was founded to mob i l ise act ion and resources aga inst malar ia

Apr. 2000 Af r ican heads of states p ledge to ha lve malar ia mor ta l i ty in Af r ica

by 2010

Sept . 2000 The MDGs, agreed by every UN member state , a r t icu la te the goa l of

ha l t ing and revers ing malar ia inc idence by 2015

Jan. 2002 The Globa l Fund , the wor ld ’s la rgest donor fo r d isease and pover ty,

is founded . I ts mandate inc ludes prov id ing fund ing fo r malar ia , H IV

and TB

Jun. 2005 The Wor ld Bank Booster Program for Malar ia Cont ro l in Af r ica is

launched . Fund ing fo r 2005 - 2008 increases n ine-fo ld f rom the

US$50 mi l l i on commit ted by the Wor ld Bank f rom 2000 to 2005

Jun. 2005 The Pres ident ’s Malar ia In i t ia t ive (PMI ) is launched , p ledging to

increase US fund ing by more than $ 1 .2 b i l l i on over 5 years

Nov. 2005 Yaoundé Dec la rat ion : commitment by the Par tnersh ip to work

towards harmon ised p lann ing , mon i to r ing and coord inat ion at count ry

leve l

Nov. 2005 The Gates Foundat ion p ledges $258.3 mi l l i on fo r research and

deve lopment

Jun. 2007 The G8 p ledges $60 b i l l i on to st rengthen hea l th systems in Af r ica

and advance the MDGs re la ted to HIV, TB and malar ia

Apr. 2008 UN Secretary-Genera l ca l ls fo r un iversa l coverage by the end of

2010

Summer ‘08 The Globa l Fund opens another round of fund ing (Round 9) to

inc rease funds ava i lab le to count r ies fo r the 2010 targets

Source: Global Malaria Action Plan.

In 2000, malaria caused 350 to 500 million clinical episodes annually, and resulted in over one mil-lion deaths. The malaria control community seized the opportunity of the MDGs discussions to draw attention to this affected additional population, and urged that the relevant MDG be broadened to cover the larger population of people suffering from malaria38.

Parliamentary advocacy: Advocacy to generate resources for malaria has particularly targeted parliamentarians. For example, the RBM’s Malaria Advocacy Working Group also has a work stream to mobilise parliamentarians to support malaria. It also names a Global Advocate for Ma-laria and European malaria champions, who work with parliamentarians and other elected officials in malaria-endemic countries to help reinforce political commitment39. Networks, such as the UK All Party Parliamentary Group on Malaria and Neglected Tropical Diseases, the European Parliamentary Fo-rum for Population & Development and the

1414

Malaria Consortium, have targeted programmes to mobilise parliamentary support in endemic as well as donor countries.

Programmatic focus of endemic countries and regions: The targeted approach of malaria programmes seems to have helped to progressively eradicate malaria in some countries. Given the high incidence of malaria in Africa, the campaign was strategic in focussing its attention on countries in the region. The Abuja Summit, attended by senior representatives of 44 African nations who committed to halve malaria mortality by 2010, is considered a landmark event. The Abuja Declaration called for resources to the order of US$1 billion per year to achieve its goals. The summit also rallied countries and organisations to act against the disease40.

“Much advocacy, in i t ia l ly

f rom the malar ia research

community and later f rom

the broader RBM partnership,

put malar ia back on the

agenda, and promintent ly

into the Brundt land-Sachs

Commission Report on

Macroeconomics & Health .

Sachs argued for malar ia

in the MDGs. MDGs led

the Global Fund and others

l ike the Gates Foundat ion

to make major investments

in research and contro l of

malar ia . ”

—Prof . Don de Savigny,

Swiss Tropical and Publ ic Health

Inst i tute

V.3. THE CASE OF TUBERCULOSIS

In the 1970s and 1980s, the International Union Against Tuberculosis and Lung Diseases (IUATLD-the Union) piloted a model to control TB in some African countries. The underlying principles of this model were adopted as the WHO DOTS strategy in 1995. In 1993, the WHO Director-General declared TB a Global Emergency, and called for urgent ac-tion. As with malaria control, associating TB with the AIDS initiative and the Global Fund significantly improved interest in the disease. The campaign has now attracted resources from multilateral agencies as well as bilateral agencies of the United States, Canada and several European countries. Some strategies that the TB campaign used to mobilise resources, which are relevant to tobacco control, are discussed below.

Evidence to validate resource needs: In addition to estimations of the burden of disease, the TB movement consolidated evidence on the following fronts in time to “make the case” for politi-cal commitment and resource needs. It demon-strated:

` the impact of TB on national economies, in terms of poverty, productivity and health care costs

` the impact of interventions

` the cost of effective interventions

` the return on investments (Figure 2)

` the potential improvement in gross domestic product (GDP) with decrease in prevalence.

“Demonstrate the costs

and the consequences of

inact ion and the returns on

investment through strategic

f inancia l support” .

— Dr. Nevin Wi lson, The Union.

15

F igure 2 . Return on Investment of one US Dol la r

0

5

10

15

20

25

30

35

0 5 10 15 20 25 30

Tuberculosis:Case Finding & Treatment

Heart Attacks:Acute Low Cost Management

Expanded Immunization

Malaria:Prevention & Treatment

HIV:Combination Prevention

Local Surgical Capacity

Ratio

Num

ber

of

peo

ple

(mill

ions

)

Year

17.3

8.66.0 5.0

2.3 1.0 0.03

40.3

TotalHealth careprofessionalassociations

Businesscommunity

Globalphilan-thropic

institutions

UN & othermulti-lateral

organizations

Civilsociety

49lowest income

countries

Allcountriesexcept

49 lowest income

High-income Middle-income Low-income

17.60 0.013

167.57

1.36

5.43 0.001

US

$ p

er c

apita

Per capita total tax revenue from tobacco products

Per capita public spending on tobacco control

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

The UN Secretary-General’s Special Envoy to Stop Tuberculosis, Jorge Sampaio, (former President of Portugal) contributed much political outreach to raise the profile of TB at international events. For instance, he exhorted G8 countries to prioritize investment in TB, and brought together ministers, heads of development agencies and other health leaders at a series of fora and discussions on TB42.

Engaging the MDGs: Divergent views exist regarding the role of MDGs in triggering financing for health concerns. However, several scholars and TB partners suggest that reference in the MDGs helped propel discussions about some of the infec-tious diseases that had been ignored for decades, such as TB, onto the global stage.

However, TB was not clearly mentioned in the MDGs. Partners in the Stop TB Partnership en-gaged MDG 6, “Combat HIV/AIDS, malaria and other diseases”, and successfully made the case for the inclusion of TB-specific indicators in the MDGs framework. The WHO Annual Global Re-port measures country performance against these globally-agreed targets. This in turn influences country performance in resource allocation and interventions. The MDGs have also brought about

Source: Modified from Report of the High-Level Panel of Eminent Persons on the Post-2015 Development Agenda, 2013.41

Strategic planning leading the way: The TB experts interviewed for this research identified the Global Plan for TB Control as having propelled country action and international resources for TB control. The first plan was developed by the Stop TB Partnership in 2005 in a participatory manner, with nearly 5,000 partners having the opportunity to shape its design. The plan offered a definite timeframe, clear objectives and deliverables that provided guidance to national TB control pro-grammes. Additionally, the recommended interven-tions were costed, which helped donors to assess the potential returns on their investments. The involvement of donor countries and agencies in de-veloping the plan helped generate a sense of own-ership, which in turn aided in attracting resources.

Partnership & champion: Like malaria and AIDS, the TB movement also followed the part-nership approach to global action. The Stop TB Partnership formed in 2001 brought together a broad spectrum of partners, such as affected people, practitioners, country programme focal points, development partners, relevant UN agen-cies and multilaterals such as the World Bank. This extremely engaged coalition gave a face to the TB problem and advocated for TB in a variety of fora, proving effective at stimulating funding.

1616

a change in donor paradigms: shifting the goal of investment from counting the people notified and cured of TB to assessing the impact of interven-tions on realising the MDGs and poverty alleviation.

“Targets are establ ished to

del iver against , and they

enl ist accountabi l i ty from al l

stakeholders , governments and

donors al ike. Those who worked

for thei r achievement , as

wel l as those who worked

against them, should be held

accountable. ”

— Dr. Lucica Dit iu , Stop TB

V.4 THE CASE OF MATERNAL AND

CHILD HEALTH

Overseas Development Assistance for MCH increased in real terms between 2003 and 2009. However, the increase in resources had reached a plateau by 201043. This led to concerns that short-falls in funding would severely affect the achieve-ment of MDG 4 (reducing childhood mortality) and MDG 5 (improving maternal health). This has in turn stimulated fresh efforts at finding additional resources for MCH since 2010.

Global Strategy: United Nations Secretary-General Ban Ki-moon seized the opportunity of the UN MDG Summit in September 2010 to revitalise resource mobilisation for MCH by launching the Global Strategy for Women and Children’s Health. The strategy, a roadmap to enhance financing, strengthen policy, and improve services for the most vulnerable women and children, requires a broad range of stakeholders to work together to save the lives of 16 million women and children by 2015.

F igure 3. Overv iew of tota l commitments p ledged by stakeho lders dur ing the MDG

Summit , New York , September 2010 (b i l l i ons of US do l la rs )

0

5

10

15

20

25

30

35

0 5 10 15 20 25 30

Tuberculosis:Case Finding & Treatment

Heart Attacks:Acute Low Cost Management

Expanded Immunization

Malaria:Prevention & Treatment

HIV:Combination Prevention

Local Surgical Capacity

Ratio

Num

ber

of

peo

ple

(mill

ions

)

Year

17.3

8.66.0 5.0

2.3 1.0 0.03

40.3

TotalHealth careprofessionalassociations

Businesscommunity

Globalphilan-thropic

institutions

UN & othermulti-lateral

organizations

Civilsociety

49lowest income

countries

Allcountriesexcept

49 lowest income

High-income Middle-income Low-income

17.60 0.013

167.57

1.36

5.43 0.001

US

$ p

er c

apita

Per capita total tax revenue from tobacco products

Per capita public spending on tobacco control

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

Note: Additional commitments have been made but could not be translated into dollar values. These estimates are made in current dollars.

Source: Modified from “Summary of Commiments for Women’s and Children’s Health” made at the Every Woman, Every Child side event hosted by United Nationsl Secretary-General Ban Ki-moon on Sept 22, 2010

17

As Figure 3 indicates, The Global Strategy for Women and Children’s Health has attracted pledges of US$40 billion from high and low-income countries and other partners44. In 2010, the G8 Muskoka Summit and subsequent Initiative on Maternal, Newborn and Child Health commit-ted member countries to collectively spend US$5 billion towards child survival and maternal health between 2010 and 2015.

Global campaign: Under the Global Strategy, the UN’s Every Woman Every Child campaign was created to spur international and national action by governments, multilaterals, the private sector and civil society to address the major MCH challenges. UN Secretary-General Ban Ki-Moon has person-ally hosted several events, and engaged media for campaign communications45. The NGO-driven Women Deliver events have also become rallying points to raise the profile of women’s health issues. Celebrities joined these efforts, lending their popu-larity to draw attention to health challenges facing children and women.

Accountability mechanisms: The Global Strategy includes a strong accountability mecha-nism that tracks and reports progress on the com-mitments made to the issue. The Commission on Information and Accountability for Women’s and Children’s Health provides oversight to the imple-mentation of the strategy. The independent Expert Review Group set up by the Commission further re-ports regularly to the UN Secretary-General on the results and resources related to the Global Strategy and on progress in implementing the Commission’s recommendations.

Similarly, Countdown to 2015 is a multi-disciplinary collaboration of academics, governments, inter-national agencies, health-care professionals’ as-sociations, donors, NGOs and the Lancet. It tracks coverage of MCH interventions with a view to im-proving them in the countdown to the deadline of MDGs in 2015. It advocates for accountability from governments and donors, identifies knowledge gaps, and proposes new actions to reduce child mortality and improve maternal health in achiev-ing MDGs 4 and 5. These multiple accountability mechanisms seem to have resulted in increased resources and improved delivery of commitments by governments and donors46.

V.5 THE CASE OF VACCINAT ION

Global vaccine coverage reached unprecedented levels in the 1980s, with The United Nations Chil-dren’s Fund (UNICEF) and WHO leading the efforts. A historic landmark was the eradication of small-pox. This was followed by a period of stagnation in immunisation rates in LMICs in the 1990s. Multiple factors contributed to the resurgence in resources for vaccination against key diseases in the latter half of the 1990s. Apart from the discovery of new vaccines, several of these factors revolved around donor engagement.

Convincing donors: Following a summit, the major players in global immunisation—key UN agencies, leaders of the vaccine industry, represen-tatives of bilateral aid agencies and major founda-tions—agreed to create a partnership. Thus, the Global Alliance for Vaccines and Immunisation (GAVI) was formed in 2000 under the leadership of the then Director-General of the WHO, Dr. Gro Harlem Brundtland, and the Gates Foundation. The Foundation’s pledge to GAVI of US$750 million over five years galvanised other donors around the issue47.

Coordinated action: The vaccine movement has established a time-bound coordination mecha-nism—the Decade of Vaccine Collaboration—with a mandate to develop a Global Vaccine Action Plan by 2012. The collaboration has brought together national governments, multilateral organisations, civil society, the private sector and philanthropic or-ganisations to identify critical policy resource gaps for vaccination48. Through this mechanism, includ-ing extensive consultation of countries and other stakeholders, the vaccine movement has been able to develop a country-led plan.

In a similar manner, the success of the polio im-munisation campaign, which led to a 99 percent drop in polio cases, is attributed largely to the work of the Global Polio Eradication Partnership49. The partnership includes Rotary International, the UN Foundation, the Bill and Melinda Gates Foundation, UNICEF, the US Centers for Disease Control and Prevention and the WHO.

Advocacy: As with the malaria partnership, the vaccine movement has a dedicated working group for public and political advocacy. It looks into the cost-effectiveness of vaccines, makes the moral case for vaccines, identifies opportunities for advo-cacy, and facilitates networking between academic and advocacy communities50.

1818

VI . RESOURCE MOBIL ISAT ION

STRATEGIES : LESSONS FROM

KEY HEALTH CONCERNS FOR

TOBACCO CONTROL

The strategies that worked to garner political will and resources for health concerns in the last two decades inform the discussions on FCTC imple-mentation. Those that are relevant and easily trans-ferable to tobacco control are discussed here.

VI . 1 DEMONSTRATING EVIDENCE

One advantage of advocating for action on tobac-co is that epidemiological evidence exists regarding the health consequences of tobacco use. There is also emerging evidence on the socio-economic consequences of tobacco use and cultivation. In the case of other public health concerns, such as malaria, advocates attracted donors’ attention by showcasing pragmatic, low-cost interventions to address the problems. Tobacco control also enjoys the benefit of proven, cost-effective interventions as enshrined in the WHO Framework Convention on Tobacco Control. As illustrated by resourcing for AIDS and TB, additional evidence that could influ-ence resource allocations includes:

` Country-specific data on the impact of the tobacco epidemic on economic development and GDP, initially in high-burden countries

` Country-level costing of FCTC interventions

` Country and global assessment of cost of ac-tion versus inaction

` Modelling potential returns on investment

` Assessment of resources available at country level, and gaps thereof

` Negative financial flows from tobacco industry sources that block domestic tobacco control resources, and

` A resource investment framework for each country.

VI .2 MESSAGING AND COMMUNICAT ION

All key informants of this research identified mes-saging and communication as critical to garner global attention and resources to public health con-cerns. There may be a case for rebranding tobacco control, keeping in mind various key audiences and simplifying FCTC language. Key themes that con-veyed the urgent need for action on the researched health concerns are as follows:

Human suffering: Affected persons and com-munities actively participated in the AIDS move-ment. They brought to the fore the sufferings of individuals and families from HIV infection. This added authenticity and visibility to the cause.

Equity: The global AIDS movement was built on human rights, social justice and equity. The dispar-ity in access to HIV drugs between the developed and low and middle-income countries, driven by powerful images of African children who had lost their parents to AIDS, moved many donors. TB and malaria campaigns additionally drew attention to the disparities in how the world responded to the AIDS crisis but continued to overlook these pre-existing diseases.

National security: Concerns that the high mortality from AIDS might cause societal instabil-ity, increase poverty, and reduce combat readiness among troops was raised in global platforms. The UN Security Council in 2000 adopted Resolution 1308 ordering HIV prevention in all peacekeeping operations51. There were similar concerns about the trans-border movement of people suffering from TB52. The possibility that a person with drug-resistant TB could board a plane and show up in another country did appeal to the latter’s national concerns.

Economic consequences: In addition to highlighting the epidemiological burden caused by these health concerns, their economic implications for productivity, poverty and health care costs were powerful arguments to act on diseases such as HIV infection, malaria and TB. This helped frame them as “diseases of poverty”, and elicited responses, including through the MDGs.

19

IMPROVING MESSAGES ABOUT THE TOBACCO EPIDEMIC

Tobacco control has the potential to create powerful messages in terms of equity, trans-border concerns, the suffering of affected people, and economic impact, all of which contributed to raising the profile of other health concerns. Risk perception theories would have to be taken into consideration when framing such messages. Some ways to enhance messaging on tobacco control include::

Human suffering: The long-term nature of the consequences of tobacco use is often a barrier in conveying urgency and evoking early action on tobacco con-trol. A major rebranding needs to engage those suffering from tobacco-related chronic diseases as well as those affected by passive smoking, in order to coun-teract the positive imagery of aggressive tobacco industry marketing. Addition-ally, tobacco control needs to highlight often overlooked impacts of tobacco use on users, including addiction and financial cost.

Raise equity concerns: Just as movements advocating for infectious dis-eases focused on disparities in access to treatments, disparities exist in tobacco control in the area of regulatory environments. Developed countries have been able to increasingly regulate tobacco industry activities in their territories. As the tobacco companies shift their markets to LMICs, the burden of diseases is following, and growing at an increasing rate. However, a stark disparity exists between the capacities of developed and developing countries to address indus-try activity.

Highlight trans-border challenges: Tobacco companies are increasingly challenging regulatory measures adopted by countries to protect the health of their people, as in the cases of Australia, Norway, Uruguay and Thailand. Low-income countries are particularly vulnerable to such industry tactics, and have limited resources to fight them, or may choose short-term, non-health related trade-offs during trade negotiations with developed countries. Tobacco compa-nies’ efforts to establish principles that thwart the sovereign rights of nations to protect the health of their people are a threat to all countries. A message that it is in everyone’s interest to enhance the capacities of vulnerable, developing coun-tries to defend regulatory environments has trans-border appeal.

Demonstrate tobacco economics: Targeted communication on the eco-nomic costs of tobacco-related diseases for households and countries, as well as its impact on development, needs to be made to ministries of finance and planning. Messaging that proven, low-cost interventions exist for tobacco con-trol can appeal to the donor community. Messaging on the economic front also needs to dispel myths that position tobacco taxation as anti-poor, and to de-nounce incentives for tobacco production.

2020

VI .3 SPEARHEADING COMMITMENTS

THROUGH LEADERSHIP

Almost all of the public health concerns discussed in this report that garnered political commitment over the last decade benefitted from champions or leaders who helped raise the profile of the issue on global platforms. In some cases, the champi-ons were UN Special Envoys, in others they were world leaders and in still others celebrities lent their names and faces to the cause.

Tobacco control could benefit from country and global champions. Having the leader of a develop-ing country with a strong tobacco-control track record spearhead the movement, duly backed by leading tobacco control countries, would help raise the profile of tobacco control in the interna-tional community. Above all, such individuals would require significant political capital, courage and leadership. A UN Special Envoy could also help promote the treaty at international platforms, and help gather political support.

F igure 4 . US government AIDS communicat ion promot ing qu i t t ing

Source: AIDS.org

“Tobacco contro l needs to showcase the poor health outcomes

for infect ious diseases due to NCDs and thei r r isk factors. For

instance, the pregnancy outcomes of women who use tobacco

could be engaged to establ ish the co-benef i ts of intervent ions

and leverage the exist ing funding streams for maternal and chi ld

health . ”

— Dr. Rachel Nugent , Univers i ty of Washington.

VI .4 SYNERGIS ING WITH EXIST ING

HEALTH AND DEVELOPMENT

PRIORIT IES

Most of the LMICs are currently facing the “double burden” of communicable and non-communicable diseases (NCDs). While global health assistance increased steadily in the last decade, it is show-ing signs of stagnation in recent years, in part due to the larger economic constraints facing most resourced economies. The donor community is therefore increasingly looking for co-benefits from interventions, hoping that this translates into better returns on their limited investments.

For example, Countdown to Zero: Global Plan To-wards the Elimination of New HIV Infections Among Children by 2015 and Keeping Their Mothers Alive, contributes synergistically to achieving the health-related and gender-related MDGs, while reducing maternal and child deaths from HIV infection.

21

Tobacco control has a similar opportunity to show-case the poor outcomes for infectious diseases or developmental priorities resulting from tobacco use. A communication from the US Government to the public (Figure 4) showcases the scope for inter-ventions that yield co-benefits to the programmes on AIDS and smoking control. Similarly, there is clear evidence that smoking exacerbates TB and smokeless tobacco use leads to poor pregnancy outcomes. It is important that such evidence is engaged to further establish the co-benefits of tobacco control interventions for TB or maternal and child health. Such co-benefits, which result in overall health improvements for individuals and communities, and can be done cost–effectively, could help tobacco control tap into the existing funding streams for other health and development priorities53.

VI .5 L INK ING WITH EMERGING HEALTH

AND SUSTAINABLE DEVELOPMENT

FRAMEWORKS

When the crisis over access to HIV treatment erupted, it was not the first time that medicines un-der patent for various other diseases and available in the West were unavailable in LMICs. It was also not news that many diseases creating tremendous burdens in LMICs, such as malaria and TB, were not benefitting from research and development dollars. Initiatives addressing these diseases there-fore needed to reposition themselves, which they indeed did by riding the emerging interest in AIDS.

Several of the informants for this research opined that tobacco control has an opportunity to similarly ride the emerging interest in NCDs (of which tobac-co is a major cause; other major NCDs risk factors are harmful use of alcohol, unhealthy diet and lack of exercise). Some also cited the need for caution in certain areas while pursing this opportunity. The main risks they cited are: the potential slowdown in the momentum that tobacco control has achieved over other NCDs risk factors, and the inadvertent opening of doors for tobacco industry interference in the guise of ‘stakeholder engagement’.

Nevertheless, tobacco is more than a health concern. For example, it challenges sustainable development by posing threats to the environ-ment: water and soil nutrients are depleted for its cultivation and forests razed for trees to fuel cur-ing barns and cigarette production, leading to soil erosion and, ultimately, butt litter54. Tobacco butts are a cause of dangerous domestic and forest fires. Tobacco use also exacerbates poverty among poor income groups by displacing household expendi-

tures on food, housing and children’s education55. The tobacco challenge therefore needs to be part of emerging discussions on the future sustainable development goals.

“The emergence of a global NCD

architecture and programming

presents an opportunity

for atobacco contro l . The

development p lanning processes

const i tute key in-country

sources to tap into. South-to-

South cooperat ion, domest ic

taxat ion and l inks with

nat ional development and NCD

frameworks are al l cr i t ica l to

f ight the tobacco industry ’s

negat ive f inancia l f lows in

countr ies. ”

— Douglas Webb, United Nat ions

Development Programme

Tobacco control reflects the essence of sustainable development (development that meets the needs of the present without compromising the ability of future generations to meet their own needs)56 by countering the harm caused by tobacco com-panies through FCTC implementation, and also contributing to improve the quality of life of current and future generations. Tobacco control also has among its interventions a sustainable means of funding, tobacco taxation, which matches the sus-tainable models of financing of the future develop-ment agenda. The sustainable development frame-work for tobacco control requires and reinforces the need for multi-sectoral coordination to address the tobacco challenge.

VI .6 L IT IGAT ION

The AIDS movement has been successful in using domestic and international lawsuits to abolish bar-riers to antiretroviral treatment access, including intellectual property rights of drug companies. The law suit of AIDS Law Project against the South African Government and the US challenge in the WTO to Brazil’s compulsory licensing of HIV drugs

2222

brought global attention to the barriers to treatment.

Similarly, trade and investment challenges in inter-national fora, along with litigation against tobacco control laws in several domestic courts, could be engaged to draw attention to the barriers facing governments that attempt to protect public health from tobacco’s harm. These activities could also be used to highlight the uniqueness of tobacco as a harmful product with no known benefits to its users.

Liability lawsuits, such as the one that led to the Master Settlement Agreement in the US in 1998, helped provide 46 US states with resources to recover the treatment costs of tobacco-related dis-eases. Similarly, the Minnesota settlement forced the public release of the tobacco industry’s previ-ously secret internal documents, providing insights into industry behaviour that have since influenced public opinion57. Low-income countries would re-quire substantial legal and other resources to plan and develop legislative frameworks and challenge the industry in a similar manner.

VI .7 SUPPORTING C IV IL SOCIETY

ACTION

The international crisis over access to HIV/AIDS treatment that gripped the developing world is widely recognised as the trigger point for global interest in AIDS. The street protests that erupted in countries like the US, South Africa and Brazil, and those that paralysed global events such as the WTO meeting in Seattle, the AIDS Conference in Durban and US presidential campaigns, forced world leaders to take steps towards providing ac-cess to antiretroviral treatment and HIV prevention.

Whereas civil society primarily played an activ-ist role in the AIDS response, it acted more as a facilitator in the case of TB. The NGOs tested interventions and developed models that came to be adopted as the DOTS strategy for TB control. They continue to be active partners in the Stop TB Partnership, influencing policy-making and deci-sions about resources for in-country programming.

Even in its response to AIDS, civil society has come to play a direct role in policy-setting and resource decisions, including on the Global Fund Board in recent years. In many countries, the Country Coor-dinating Mechanism (CCM) has helped to democ-ratize the national health response to the issue and engage stakeholders beyond the public sector in setting country priorities58.

“Civ i l society organisat ions

have proved effect ive members

of the Global Fund Board ,

where they hold equal vot ing

r ights alongside the pr ivate

sector, donors and recip ient

governments. Civ i l society

players in-country br ing a

sense of real i ty and immediacy

to Board discussion and pol icy

development” .

— Global Fund to f ight AIDS,

Tuberculosis and Malar ia .

23

VI I . RECOMMENDATIONS TO

THE FCTC CONFERENCE OF

THE PARTIES

VI I . 1 IDENT IFY BARRIERS TO

TREATY IMPLEMENTATION

The history of almost all the health issues that mobilised international support over the years is marked by a phase of identifying challenges, fol-lowed by one seeking solutions and eventually by a period of advocating their efficacy.

Similarly, countries need to first identify the specific barriers they face in implementing the FCTC. These barriers could range from lack of public support or political will within the country, absence of coordi-nation among various agencies of the government, financial resource constraints amidst competing health and developmental priorities, technical and technological challenges and extraneous influences on the country’s trade and investment policies to tobacco industry opposition to control measures.

Governments need to engage the Working Group on Sustainable Measures to Strengthen Implemen-tation of the WHO FCTC, set up by the Conference of the Parties (COP), to closely examine the broad range of barriers to treaty implementation with a view to seeking appropriate solutions.

VI I .2 DEVELOP GLOBAL

STRATEGY, COSTED PLANS

& MODEL RETURNS ON

INVESTMENT

The FCTC COP develops biennial workplans. A longer term global strategy for FCTC implementa-tion, along with an investment framework and a business plan, would be critical from a resource mobilisation perspective. COP6 could mandate the development of a longer term, multi-pronged strategy for sustainable FCTC implementation and a business plan to enhance treaty implementation.

Tobacco control interventions have been proven to reduce tobacco use and require minimal resources to set up. For instance, the cost of implementing just four of the proven tobacco control demand reductions measures that are required by the FCTC totals US$0.40 per person per year in low and lower-middle-income countries, and US$0.50–1.00 in upper-middle-income countries59. It is important that these figures are supplemented by costing for governments concerning the full and effective implementation of the FCTC. More importantly, it is important to demonstrate to donors the potential

return on their investment, including co-benefits in terms of outcomes for other health challenges and economic improvements in terms of country GDPs. A business plan that shows “investments required against anticipated returns” for FCTC implementa-tion needs to be developed to inform the COP as well as the donor community. It should also envis-age long-term scenarios for sustaining tobacco control when tax revenues recede from decreased sales as well as the transition of individuals depen-dent on tobacco-related livelihoods.

VI I .3 BUILD A POL IT ICAL

STRATEGY TO ENHANCE

COMMITMENT TO TOBACCO

CONTROL

A lesson from other health initiatives is that in ad-dition to programme strategy and costed plans, tobacco control requires a political strategy to attract global and national attention and resource commitments. This would require political map-ping to identify key target audiences, agencies and leaders, and the development of evidence-based messaging that appeals to their interests. Key plat-forms to promote FCTC implementation need to be identified, be they via links to NCDs, development or other movements, and messengers must be equipped to advocate the cause. The political strat-egy may also involve forging strategic partnerships with relevant agencies and movements. Civil soci-ety needs to be supported to undertake advocacy for the treaty at the country and global levels.

FCTC workplans typically include general aware-ness raising activities. These need to be augment-ed by active Party-led, high-level advocacy efforts that raise the profile of the treaty at global plat-forms and international events, some of which will need to be created. The COP needs to establish an FCTC Advocacy Support Group (similar to the Malaria Advocacy Working Group of the Roll Back Malaria Initiative) that would work with countries, the treaty Secretariat and civil society to develop a political strategy for treaty promotion, and identify and engage a broad range of strategies and op-portunities for FCTC advocacy.

VI I .4 UT IL ISE THE NCDS AND

DEVELOPMENT FRAMEWORKS TO

ADVANCE FCTC IMPLEMENTATION

The MDGs enhanced action and resources at national and global levels for the health concerns that they addressed. Goals, targets and indicators in the MDGs framework helped those working on

2424

these issues to track progress, advocate account-ability, and evaluate outcomes. NCDs should be included among the health priorities for the post-2015 development framework. As the future sus-tainable development agenda is being ironed out

by UN Member States, it is important that coun-tries seize the opportunity to ensure that tobacco control is well articulated, with specific targets and indicators, within its framework. The NCD Global Monitoring Framework, including the tobacco tar-get and indicators, could inform these efforts.

MALARIA ADVOCACY WORKING GROUP—

LESSONS FOR TOBACCO CONTROL

The Malar ia Advocacy Work ing Group (MAWG) coord inates the advocacy

ef fo r ts of the Ro l l Back Malar ia Par tnersh ip to inc rease the a l locat ion

of resources fo r malar ia cont ro l . I ts mandate inc ludes scout ing and

ident i fy ing oppor tun i t ies fo r ef fect ive advocacy at g loba l , reg iona l and

nat iona l leve ls. The group a lso d isseminates accurate in fo rmat ion on

resource a l locat ions to improve accountab i l i ty both by donors and

imp lementers.

There is scope fo r a s im i la r FCTC Advocacy Suppor t Group to be

set up by the FCTC Conference of the Par t ies to advocate resource

mob i l isat ion fo r t reaty imp lementat ion. Such a commit tee cou ld compr ise

deve loped and deve lop ing count ry par t ies , deve lopment par tners ,

mul t i la te ra l and non-governmenta l agenc ies and ph i lanthrop ies , to the

exc lus ion of tobacco in te rests.

The commit tee cou ld prov ide st rategic counse l to the COP and the

t reaty Secretar ia t on oppor tun i t ies fo r t reaty advocacy at nat iona l ,

reg iona l and g loba l leve ls. I t cou ld “open doors” to add i t iona l resources ,

and work wi th the COP and deve lopment par tners to improve

accountab i l i ty of both donors and imp lementers.

25

VI I .5 FCTC COUNTDOWN

2025—ACCELERATE TREATY

IMPLEMENTATION

Even as 2013 marks a decade since the adop-tion of the FCTC, treaty implementation is yet to gain momentum in most countries. In May this year, WHO Members States, (the majority of which are also Parties to the FCTC), adopted the Global Monitoring Framework for NCDs. Among its indica-tors, the Member States agreed to a 30 percent reduction in tobacco prevalence by 2025. This ambitious target provides governments a defini-tive timeline within the first quarter of the century to achieve significant reductions in tobacco use in their respective territories, and an avenue to col-laborate for international action. Future success requires that countries accelerate their efforts at treaty implementation and that support for the same increases many fold. An FCTC Countdown 2025 campaign, similar to the Countdown to 2015 campaign for MCH challenges, could guide and accelerate Party efforts in a time-bound manner.

VI I .6 REBRAND AND DEVELOP A

COMMUNICAT IONS STRATEGY

Given the critical role that messaging played in accelerating global action on other public health concerns, it is important that the FCTC has a clear branding and communications strategy, and that it consider developing messages for diverse audi-ences. For example, a resourced country that has faced tobacco industry challenges can identify and respond to the need for creating equitable regulatory environments in countries targeted by the industry. A philanthropy that supports control of infectious diseases may need to be specifically informed as to how tobacco control interventions can contribute to health improvements for those diseases. A full communications strategy would involve researching country needs, generating tailored messages that appeal to diverse target groups, engaging credible messengers, and then evaluating the outcomes of such efforts to improve the strategy.

VI I .7 MOBIL ISE DOMESTIC AND

INTERNATIONAL COMMITMENTS

AND RESOURCES

Experience from other public health funding efforts indicates that international assistance tailored to stimulate domestic resources leads to sustain-ability of interventions. For instance, GAVI provides catalytic grants and expects countries to mobilise resources to sustain the initial investments60. Simi-larly, after early years in which international funding was predominant, in 2011 domestic funding under-pinned progress in TB control in the BRICS (Brazil, Russia, India, China and South Africa, where 50 percent of TB cases occur), as well as in European, Latin American and upper-middle income countries, making them increasingly self-sufficient61.

Implementing tobacco control requires minimal resources as already proven preventive measures exist. For instance, mandating warning labels on tobacco products requires simply research on effective warnings and initial enforcement checks. Similarly, smoke-free laws tend to be self-sustain-ing following initial enforcement drives and once norms are established. Some of the tobacco control measures, such as taxation, even generate revenue that can offset costs.

WHO estimates that governments collect nearly US$133 billion by way of tobacco excise taxes. However, they spend less than US$1 billion com-bined on tobacco control62. Less than 10 percent of LMICs have taxes constituting 50 percent of the retail price, while WHO recommends tobacco taxes make up 75 percent of the retail price for ef-fective reduction in tobacco use. Further, as Figure 5 indicates, there is wide difference in per capita revenue earned from tobacco products and per capita spending on tobacco control across coun-tries, with the difference being steeper for low and middle income nations. There is therefore tre-mendous scope to increase tobacco taxes to the WHO-recommended benchmark across countries, and use part of the revenue for tobacco control and prevention efforts.

Domestic resources are essential for long-term sustainability of tobacco control programmes in countries. Resources at the domestic level far exceed international assistance for almost all development and health issues. Current low-and-middle income country health spending exceeds aid 18:163.

2626

F igure 5. Per-cap i ta pub l ic spend ing on tobacco cont ro l and per cap i ta revenues

co l lected th rough tobacco taxes

0

5

10

15

20

25

30

35

0 5 10 15 20 25 30

Tuberculosis:Case Finding & Treatment

Heart Attacks:Acute Low Cost Management

Expanded Immunization

Malaria:Prevention & Treatment

HIV:Combination Prevention

Local Surgical Capacity

Ratio

Num

ber

of

peo

ple

(mill

ions

)

Year

17.3

8.66.0 5.0

2.3 1.0 0.03

40.3

TotalHealth careprofessionalassociations

Businesscommunity

Globalphilan-thropic

institutions

UN & othermulti-lateral

organizations

Civilsociety

49lowest income

countries

Allcountriesexcept

49 lowest income

High-income Middle-income Low-income

17.60 0.013

167.57

1.36

5.43 0.001

US

$ p

er c

apita

Per capita total tax revenue from tobacco products

Per capita public spending on tobacco control19

90

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

Source: WHO report on the global tobacco epidemic, 2011.

“ In the long run, governments wi l l need to devote more of thei r

own resources to establ ish and enforce thei r tobacco contro l

programmes. Tobacco contro l measures are cost-effect ive and,

in the case of excise taxes, revenue generat ing , but not f ree.

They cost money to establ ish and enforce. More internat ional

a id is needed to provide start-up investment in tobacco contro l

expert ise and capacity, and to establ ish the mechanisms l ike

taxat ion that can further sustain the efforts over the long-term.”

—Thomas Bol lyky, Counci l on Foreign Relat ions.

27

However, early start-up support, mainly to estab-lish mechanisms that would develop and defend tobacco control policies and programmes, can accelerate efforts to reign in the tobacco epidemic, which is rapidly expanding in the LMICs64. This could include, among others, support to: assess country needs and barriers; develop and enact policies and tax plans; set up inter-sectoral coordi-nation mechanisms for tobacco control; integrate tobacco control into the country’s development plans, and build legal and technical capacity for defending tobacco control measures. International resources need to support work in both LMICs with high tobacco prevalence as well as in coun-tries that currently have low smoking rates, but face heavy tobacco marketing. National political and financial capacity to counter tobacco industry efforts and reduce tobacco use need to guide the resource decisions.

VI I .8 FORGE ALL IANCES

Experience from other public health concerns indicates that engaging a broad range of com-mitted partners could help leverage each one’s strengths and resources. In the case of tobacco control, this would need to include ways to protect such alliances from tobacco industry influence. An FCTC Article 26† Coalition could be a platform where countries that are less resourced or vulner-able to tobacco industry attacks could access the support required to enhance and defend their tobacco control programmes. Such networking could provide donors an opportunity to understand and streamline their response to the challenges of less-resourced settings. Clear terms of reference and strong accountability mechanisms could make this a productive engagement platform for both resourced and less-resourced countries to propel FCTC implementation.

Such coalitions are needed in every country, and should involve diverse government agencies, municipalities, worker’s groups, women’s groups, youth groups, religious organisations and media. An active people’s movement is critical to address political roadblocks and ensure multi-sectoral ac-tion.

† FCTC Article 26 deals with financial and other resources for treaty implementation.

“An FCTC Art ic le 26 Coal i t ion  is

needed to br ing together

a broad set of pro-health

stakeholders to support strong

implementat ion of the treaty. An

effect ive and broad coal i t ion

would ra ise tobacco contro l at

country level and in the global

pol i t ica l agenda.”

— Dr Sarah England,

Bloomberg Phi lanthropies

2828

TOBACCO TAX CAMPAIGN

Tobacco contro l has an bui l t- in instrument to generate revenue in

the short to medium term: tobacco taxes. They also const i tute the

single most effect ive measure to reduce tobacco use. The tobacco

industry opposes any increase in tobacco taxes, making i t

pol i t ica l ly chal lenging, whi le earmarking them for tobacco contro l

is often resisted by ministr ies of f inance.

Industry arguments need to be countered with evidence regarding

the eff icacy of taxes to reduce consumpt ion, y ie ld savings on

indi rect costs to households and the economy, and generate

revenue for health promot ion. Strong partnerships need to be bui l t

between ministr ies of health and civ i l society, inc luding support

for c iv i l society advocacy to persuade re levant government

sectors to implement consistent and effect ive increase in tobacco

taxes and suff ic ient resourc ing of tobacco contro l .

The chal lenges facing countr ies that are consider ing increasing

tobacco taxes and al locat ing revenue indicates the need for

pre l iminary internat ional resourc ing to help set up tax plans.

Technical and f inancia l resources are requi red from development

partners to bui ld evidence, develop tax and long-term resource

mobi l isat ion plans, improve tax administrat ion , re inforce

enforcement , support tax advocacy campaigns, and f ight industry

chal lenges with a view to mobi l ise in-country resources for

tobacco contro l .

The Conference of the Part ies needs to launch a Global Tobacco

Tax Campaign with a two-pronged object ive : st imulate in-country

resources for tobacco contro l , and encourage donors to provide

resources for countr ies ’ taxat ion efforts.

29

VI I I . CONCLUSION

The experiences of the public health concerns researched for this paper demonstrate that it is critical and feasible to garner political and resource support for FCTC implementation, globally and in countries. Ef-forts need to begin by identifying the barriers to implementation, developing a political and programmatic strategy, and communicating a sense of urgency for action. Political leadership and multi-sectoral action would be critical in enhancing treaty implementation.

Governments need to seize the opportunity of the Working Group on Sustainable Measures to Strength-en the Implementation of the WHO FCTC to address the barriers, identify pathways, and recommend solutions to the next Conference of the Parties in 2014. The COP, and the global tobacco control move-ment more broadly, need to learn from the strategies engaged by other public health movements to de-sign similar initiatives, be they high-level advocacy, long-term strategies or well-promoted studies on the economic advantages of tobacco control.

3030

REFERENCES

1. Tobacco. [Factsheet] No.339. Media Centre. World Health Organization. Updated July 2013.

2. Jha P, Chaloupka FJ, Moore J, Gajalakshmi V, Gupta PC, Peck R, et al. Tobacco addiction. In: Disease control priorities in developing countries. Jamison DT, Breman JG, Measham AR, et al., editors. New York, NY: Oxford University Press; 1996. p. 869-86.

3. WHO Report on the Global Tobacco Epidemic, 2013. World Health Organization. 2013.

4. 2012 Global progress report on implementation of the WHO Framework Convention on Tobacco Control. World Health Organization.

5. Decisions. 65th World Health Assembly, 2012. WHA decision WHA65(8), last accessed on 20 September, http://apps.who.int/gb/ebwha/pdf_files/WHA65-REC1/A65_REC1-en.pdf#page=65.

6. Follow-up to the Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases. Sixty-Sixth World Health Assembly. WHA66.10. Agenda item 13.1 & Agenda item 13.2. 27 May 2013.

7. WHO Report on the global tobacco epidemic, 2011. Warning about the dangers of tobacco. World Health Organization. 2011.

8. Ravishankar N, Gubbins P, Cooley RJ, Leach-Kemon K, Michaud CM, Jamison DT, Murray CJL. Financing of global health: tracking development assistance for health from 1990 to 2007. The Lancet, Volume 373, Issue 9681. 2009: 2113–24.

9. Financing the Response to HIV in Low- and Middle-Income Countries: International Assistance from Donor Governments in 2012. UNAIDS & the Henry J. Kaiser Family Foundation. September 2013.

10. Nugent RA & Feigl AB. Where Have All the Donors Gone? Scarce Donor Funding for Non-Communicable Diseases. CGD Working Paper 228. Washington, DC: Center for Global Development. 2010.

11. Thomas M. Daniel. The history of tuberculosis. Respira-tory Medicine. November 2006. Volume 100, Issue 11. 1862–1870. http://www.sciencedirect.com/science/ar-ticle/pii/S095461110600401X

12. The History of Malaria, an Ancient Disease. Centres for Disease Control and Prevention. http://www.cdc.gov/ma-laria/about/history/

13. Dolin PJ, Raviglione MC and Kochi A. Global tuberculosis incidence and mortality during 1990-2000. Bull World Health Organ. 1994; 72(2): 213–220.

14. Reported Malaria Deaths, 1990-2010. World Malaria Re-port 2011. Annex 6 D. Global Malaria Programme. World Health Organization. 2011.

15. The Millennium Development Goals Report 2009. United Nations. New York. 2009.

16. Access to HIV/AIDS Treatment in Developing Countries. Interagency Coalition on AIDS and Development. [Revised August 2001].

17. Bollyky TJ. From HIV to NCDs: Will Patent Fights Again Spur Better Treatment Access? PLOS Medicine, Vol. 10, No. 7. July 2013.

18. Origins of GAVI. GAVI Alliance. http://www.gavialliance.org/about/mission/origins/, last accessed on 2 September 2013.

19. The Muskoka Initiative: Background. Foreign Affairs, Trade and Development Canada. http://www.acdi-cida.gc.ca/acdi-cida/acdi-cida.nsf/En/FRA-119133138-PQT

20. The World Health Report 1999—Making a Difference. WHO (World Health Organization). Geneva: WHO. 1999.

21. Global Fund Mid-2013 Results. [Factsheet]. The Global Fund to Fight AIDS, Tuberculosis and Malaria. 2013.

22. Demography and economics of HIV/AIDS. British Medical Bulletin. Volume 58, Issue 1. 73-88.

23. King J. Life Patents and AIDS drug access. Council for Responsible Genetics. http://www.councilforresponsible-genetics.org/ViewPage.aspx?pageId=164, last accessed on 25 August 2013.

24. Samanta Sen. British NGOs support Pretoria against pharmaceutical firms. Third World Network. April 2001. http://www.twnside.org.sg/title/pretoria.htm, last ac-cessed on 2 September 2013.

25. Médecins Sans Frontières. Access Campaign website. http://www.msfaccess.org/content/1998-big-pharma-ver-sus-nelson-mandela, last accessed on 25 August 2013.

26. Minister of Health and Others v Treatment Action Cam-paign and Others (No 2) (CCT8/02) [2002] ZACC 15; 2002 (5) SA 721; 2002 (10) BCLR 1033 (5 July 2002). South Af-rica Legal Information Institute. Available from: http://www.saflii.org/za/cases/ZACC/2002/15.html, last accessed on 11 October 2013.

27. Former President of Brazil, Fernando Henrique Cardoso: A most public sociologist. Footnotes. Volume 32, Number 3. March 2004. Available from: http://www.asanet.org/footnotes/mar04/index.html, last accessed on 25 Sep-tember 2013.

28. What the world summit means for Africa. Commitments on aid, debt relief and MDGs are reaffirmed. Africa Re-newal: October 2005. p4. http://www.un.org/africarenew-al/magazine/october-2005/what-world-summit-means-africa, last accessed on 25 September 2013.

29. Secretary-General proposes Global Fund for fight against HIV/AIDS and other Infectious Disease at African Lead-ers Summit. Press release. SG/SM/7779/Rev.1. United Nations. 26 April 2001. http://www.un.org/News/Press/docs/2001/SGSM7779R1.doc.htm, last accessed on 25 August 2013.

30. The Global Fund to Fight AIDS, Tuberculosis and Malaria. Country coordination mechanisms. Available from: http://www.theglobalfund.org/en/ccm/.

31. UNAIDS. 2000 Millennium Development Goals. Available from: http://www.unaids.org/en/aboutunaids/unitednationsdeclarationsandgoals/2000millenniumdevelopmentgoals/

32. UNAIDS. Declaration of Commitment on HIV/AIDS.

33. Global Malaria Action Plan. http://www.rollbackmalaria.org/gmap/1-3.html, last accessed on 26 August 2013.

34. Trends in International Funding for Malaria Control. Back Malaria Partnership Finance and Economics Working Group (FEWG). Commissioned report by Waddington C, Martin J & Walford C. HLSP Institute. August 2005.

31

35. Matt Lynch. Good News about Malaria: JHU∙CCP’s Matt Lynch Reflects on the Malaria Forum. http://www.jhuccp.org/news/success_stories/good-news-about-malaria-jhu.ccp’s-matt-lynch-reflects-malaria-forum, last accessed on 26 August 2013.

36. Malaria. The Global Fund to Fight AIDS, Tuberculosis and Malaria. Available from: http://www.theglobalfund.org/en/about/diseases/malaria/.

37. Global Malaria Action Plan for a Malaria Free World. Roll Back Malaria. http://www.rbm.who.int/gmap/4-2.html, last accessed on 2 September 2013.

38. Chronology of Milestones. Malaria. Center for Global Health and Economic Development. Earth Insti-tute. Columbia University. http://cghed.ei.columbia.edu/?id=malaria_timeline, last accessed on 2 September 2013.

39. Successful Parliamentary Advocacy on Malaria. Best practices from EPF Malaria Taskforce. [Booklet]. European Parliamentary Forum on Population and Development.

40. A decade of partnership and results. Progress & Impact Series. Number 7. Roll Back Malaria Partnership. Septem-ber 2011.

41. A New Global Partnership: Eradicate Poverty and Trans-form Economies through Sustainable Development. The Report of the High-Level Panel of Eminent Persons on the Post-2015 Development Agenda. United Nations. 2013.

42. A voice for the poor and marginalized—Jorge Sampaio honoured for political advocacy on TB. News Stories. Stop TB Partnership: April 2013. http://www.stoptb.org/news/stories/2013/ns13_029.asp, last accessed on 28 August 2013.

43. Hsu J, Pitt C, Greco G, Berman P, Mills A. Countdown to 2015: Changes in official development assistance to maternal, newborn, and child health in 2009-10, and assessment of progress since 2003. The Lancet, Volume 380, Issue 9848. 2012: 1157-1168.

44. The Global Campaign for the Health Millennium Develop-ment Goals 2010. Putting the Global Strategy for Wom-en’s and Children’s Health into action. Ministry of Foreign Affairs, Norway. Oslo, November, 2010.

45. Every Woman Every Child website. Available from: http://www.everywomaneverychild.org/about.

46. Countdown to 2015. Maternal, New Born and Child Survival. http://www.countdown2015mnch.org/, last ac-cessed on 2 September 2013.

47. Origins of GAVI. GAVI Alliance. http://www.gavialliance.org/about/mission/origins/.

48. Global Health Leaders Launch Decade of Vaccines Col-laboration. Bill & Melinda Gates Foundation. Press release. http://www.gatesfoundation.org/Media-Center/Press-Re-leases/2010/12/Global-Health-Leaders-Launch-Decade-of-Vaccines-Collaboration.

49. What we do: Polio Eradication Initiative. United Nations Foundation. Available from: http://www.unfoundation.org/what-we-do/campaigns-and-initiatives/polio-eradication-initiative/.

50. Decade of Vaccine Collaboration. Available from: http://www.dovcollaboration.org/about-us/working-groups/public-political-support/.

51. United Nations. AIDS as a security issue [Factsheet]. UN Special Session on HIV/AIDS. 25-27 June 2001. New York. Available from: http://www.un.org/ga/aids/un-gassfactsheets/html/fssecurity_en.htm.

52. Tuberculosis Fact Sheet No 104. World Health Organiza-tion. Revised August 2002. http://www.who.int/mediacen-tre/factsheets/who104/en/print.html.

53. Staying Healthy with HIV/AIDS: Taking Care Of Yourself: Smoking & Tobacco Use. AIDS.gov. http://aids.gov/hiv-aids-basics/staying-healthy-with-hiv-aids/taking-care-of-yourself/smoking-tobacco-use/.

54. Reddy SK, Pachauri RK, Saran S. Can we let this mass murderer run free? The Hindu. 14 August 2013.

55. Tobacco and poverty: A vicious cycle. World Health Orga-nization. 2004.

56. Report of the World Commission on Environment and Development: Our Common Future. Transmitted to the General Assembly as an Annex to document A/42/427

- Development and International Co-operation: Environ-ment. UN Documents.

57. Richard D. Hurt, Jon O. Ebbert, Monique E. Muggli, Nikki J. Lockhart & Channing R. Robertson. Open Doorway to Truth: Legacy of the Minnesota Tobacco Trial. Mayo Clin Proc. 2009 May; 84(5): 446-456.

58. The Global Fund to fight AIDS, Tuberculosis and Malaria. Civil Society. http://www.theglobalfund.org/en/about/part-nership/civilsociety/, last accessed on 29 August 2013.

59. Asaria P, Chisholm D, Mathers C, Ezzati M, Beaglehole R. Chronic disease prevention: health effects and financial costs of strategies to reduce salt intake and control tobacco use. The Lancet. Volume 370, Issue 9604. 2007 Dec 15; 2044-53. Epub 2007 Dec 11.

60. WHO Europe. GAVI Alliance. http://www.euro.who.int/en/what-we-do/health-topics/disease-prevention/vaccines-and-immunization/activities/immunization-systems/gavi-alliance.

61. Katherine Floyd, Christopher Fitzpatrick, Andrea Pan-toja, Mario Raviglione. Domestic and donor financing for tuberculosis care and control in low-income and middle-income countries: an analysis of trends, 2002-11, and requirements to meet 2015 targets. The Lancet Glob Health 2013;1: 105-115.

62. WHO Report on the global tobacco epidemic. Warning about the dangers of tobacco. World Health Organization. 2011.

63. Thomas Bollyky. Big Data, Better Global Health. Expert Brief: Noncommunicable Diseases. Council on Foreign Relations. 21 February 2013.

64. Jackson-Morris A, Latif E. Strengthening government tobacco control in low- and middle-income countries: a ‘must do’ for lung health progress. Int J Tuberc Lung Dis. 2013 Aug;17(8):997-1000. doi: 10.5588/ijtld.13.0138.

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