Compliance and enforcement of laws for the prevention of NCDs: Examples from the Western Pacific Region and beyond

Published by: McCabe Centre for Law & Cancer
Date: June 2023

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Foreword

There’s no denying that addressing noncommunicable disease is one of the greatest public health challenges we face.

Cancer and other NCDs represent seven out of every ten deaths worldwide and kill 41 million people each year.

While those are confronting statistics, there are effective and powerful tools we can use to help reduce the incidence of cancer and NCDs, including law.

We know that strong and well-drafted laws have the power to reshape social norms, stop industry interference, and remove barriers to good health.

But laws can only be effective if they lead to change on the ground – which is why we have worked with WHO in the Western Pacific Region to compile this report on good practices in compliance and enforcement.

Enforcing and ensuring compliance with the law can be challenging at the best of times, and more so where resources are constrained. The recent impact of COVID-19 has also exacerbated these challenges – with industry actors using the pandemic as an opportunity to expand their influence and reach.

This report looks to the Western Pacific Region and beyond to demonstrate successful examples of compliance with, and enforcement of, NCD

legislation in the hope that these can serve as a guide for further progress.

We also provide practical examples of collaboration, and how working with governments, authorities and communities is essential in ensuring laws translate into real-life action.

Take for example, Singapore’s Orchard Road No Smoking Zone, which drew on the work of volunteers to promote no smoking areas in public as a social norm. Another example is Thailand’s alcoholic beverage law, which is a 3-tier system that includes collaboration between different agencies, ministries, experts and civil society organisations, working together to ensure compliance with alcohol control measures.

We can’t do this work on our own. We’d like to thank our contributors and our alumni networks who inform our work and give us greater insight into the nuances and complexities of their countries. The work we do is also possible because of the work of the WHO, the Pacific Community (SPC), and their respective member states.

It’s clear from this report that drafting and enacting well-thought-out laws is the beginning of a much longer process to turn laws into action. Compliance and enforcement are critical to this process. They cannot simply be an afterthought.

We hope this report helps to highlight how enforcement is an integral part of the puzzle and can help us as we work towards a healthier future for the Western Pacific region, and the world.

Executive summary

Noncommunicable diseases, or NCDs, are responsible for 80% of all deaths in the Western Pacific Region. ¹ In order to prevent NCDs like cancer, it is vital for governments to adopt  laws which address NCD risk factors, but also actively enforce compliance with those laws. This is because laws must be translated into tangible actions – such as changes in behaviour or policy – to achieve their public health objectives. Strengthening NCD laws and their implementation is critical to ensuring that laws on paper become action on NCDs in practice.

Enforcing laws can be particularly challenging in low- resource settings such as in low- and middle-income countries. This can be compounded by factors like industry interference from well-resourced commercial actors, and circumstances like the COVID-19 pandemic.

This report aims to support Member States in the Western Pacific Region to more effectively enforce laws and regulations to prevent NCDs. It includes case studies of successful compliance and enforcement, as well as legislative examples, from a range of resource settings in the Western Pacific Region and beyond, with a focus on practices and mechanisms that are feasible in low- and middle- income countries.

The report identifies four lessons:

Lesson one: Build enforcement in from the start of the drafting process

Well-designed, clear, comprehensive, and enforceable laws are critical to compliance and are more effectively enforced. For example, in Niue, tobacco control legislation clearly defines key terms such as ‘tobacco’ and ‘tobacco product’ to ensure that rules, sanctions, and mechanisms employing these terms are enforceable (see Box 2). Laws which are well targeted are also more likely to obtain high levels of compliance, and are easier to enforce (see Box 3).

Lesson two: Create systems to promote and monitor compliance

Governments should both promote and monitor compliance with the law. Compliance can be promoted by making regulated entities aware of their obligations, as well as informing the public about what is prohibited. For example, in Singapore, providing nutrition labelling guidance to manufacturers and importers supports compliance efforts (see Box 6). Community buy-in also promotes compliance and can reduce the need for enforcement. In Chile, this was achieved through an effective communications campaign to raise awareness of new legal requirements and mobilise civil society support (see Box 5).

Monitoring compliance with the law also helps to detect and correct violations. This can be done through inspections and investigations (see Box 7), mandating recordkeeping and reporting (see Box 8), and complaints systems (see Box 9). These mechanisms and activities are efficient ways to achieve voluntary compliance and minimise the need for more serious interventions, such as sanctions and legal action. In an effective compliance and enforcement strategy, they form the bulk of activities undertaken by law enforcement authorities and agencies.

The case studies also show the importance of the ability to respond to violations in various ways, such as by way of warnings and administrative orders (see Box 14), penalties and sanctions (see Boxes 15 and 16), legal action (see Box 17), and licence suspension or cancellation (see Box 18). Transitional periods, prior to enforcing new laws, can provide regulated persons and entities time to prepare for meeting their obligations (see Box 4).

Lesson three: Ensure that enforcement agencies are adequately resourced and can enforce the law

Countries should also consider what kinds of compliance and enforcement powers are most appropriate to achieve the aims of the law, as well as what resources may be needed. This includes monitoring powers like the power of entry and inspection (see Box 10), investigation powers such as the power to seize unlawful products (see Box 11), administrative compliance powers such as the power to issue formal warnings (see Box 12), and legal action and prosecution powers such as the power to commence legal proceedings and to seek to impose penalties (see Box 13). It is important to consider how resources for enforcement will be allocated, and to make appropriate provisions for this within the relevant budgetary processes.

Legislation must also confer responsibility for enforcement on authorised entities and officers to ensure that enforcement activities are carried out. For example, in the Republic of Korea, anti-smoking advisors may be appointed under a legislative mechanism to enforce smoke free laws (see Box 19). In New Zealand enforcement officers are appointed under legislation to monitor and enforce smoke free laws (see Box 20).

Lesson four: Work across sectors and levels of government

While local authorities are often well placed to enforce NCD laws and regulations (see Box 21), implementing an effective enforcement program generally requires a collaborative approach, where different sectors and levels of government work together to ensure that policies are implemented coherently and that there is adequate political commitment from all relevant agencies. In Thailand, a 3-tier system, established under the country’s alcohol control legislation, promotes multisectoral coordination to implement and enforce the law between various government agencies and ministries, as well as between provincial and national government agencies (see Box 22). In Quezon City, Philippines, a local government order mandates the City Administrator to coordinate with national government agencies for the implementation of a healthy food procurement policy (see Box 26).

Involving the public to promote compliance and implement the law is also important (see Boxes 23 and 24). In addition, ongoing planning is required to implement and enforce legal measures, (see Box 25), as well as regular monitoring and evaluation of the effectiveness of such measures and enforcement programs (see Box 27).

Introduction to the enforcement of laws for the prevention of NCDs

Noncommunicable diseases (NCDs) kill around 41 million people each year and are responsible for 71% of all deaths globally. ² The burden of NCDs is particularly high in the Western Pacific Region where NCDs are responsible for 80% of all deaths. ³ In low-resource settings, such as low- and middle-income countries, NCD-related healthcare costs and loss of working capacity have a particularly devastating impact on household resources, forcing millions of people into poverty each year. ⁴

Legislation is crucial to addressing NCD risk factors, such as tobacco, alcohol, and unhealthy diets. Appendix 3 of the Global Action Plan for the Prevention and Control of NCDs 2013-2030 recommends cost-effective policy interventions known as ‘Best Buys’. These include regulatory measures such as price and tax measures, smoke free laws, packaging and labelling measures, regulating sale to and by minors, marketing bans and restrictions, and regulating supply and demand of unhealthy commodities such as tobacco, alcohol, and unhealthy foods. ⁵ Many countries in the Western Pacific Region have enacted, or are enacting, legislation to implement these ‘Best Buys’ and better protect the health of their population.

However, it is not enough simply to enact laws. Laws must be translated into tangible actions – such as changes in behaviour or policy – to achieve their public health objectives and reduce the burden of NCDs. Compliance and enforcement are a key part of ensuring that laws on paper become action on NCDs in practice.

Effective enforcement of NCD laws is particularly important in light of the challenges posed by the COVID-19 pandemic. NCDs put people at higher risk of complications from COVID-19. NCD risk factors may also increase the chances of contracting the virus, and its severity. ⁶ Moreover, unhealthy commodity industries have taken advantage of the COVID-19 pandemic by adapting their digital marketing and product promotion efforts, using corporate social responsibility initiatives, and pursing collaborations to expand their influence, protect their interests, and promote their harmful products. ⁷ For example, unhealthy commodity industries, such as tobacco, alcohol and unhealthy food industries, have promoted online sales during the COVID-19 pandemic, ⁸ and have sought to link their products with health services through gifts and donations. ⁹ These industries have also sought to shape public health policies including by challenging and interfering with health and environmental regulation and its enforcement. ¹⁰ These developments pose new challenges for the enforcement of laws to combat NCDs, at a time when such laws are more important than ever.

In addition, countries operating in low-resource settings face special challenges in effectively implementing and enforcing laws including lack of resources, training, and capacity. Countries operating in both low and high-resource settings face additional challenges, such as lack of coordination between critical sectors, lack of political will, and poor civil society engagement.

This report aims to support Member States in the Western Pacific Region to more effectively enforce laws and regulations to prevent NCDs. It includes case studies of effective compliance and enforcement activities, as well as legislative examples, from a range of resource settings in the Western Pacific Region and beyond, with a focus on practices and mechanisms that are feasible in low- and middle-income countries.

What is compliance and enforcement?

Compliance and enforcement are key to achieving the objectives of NCD laws. This is because well-designed laws provide little benefit if they are not complied with and enforced. To be effective, NCD laws require appropriate compliance and enforcement action to meet their objectives and protect public health.

Compliance refers to regulated persons acting consistently with their legal obligations and requirements. Enforcement generally relates to actions taken by government bodies or agencies to achieve compliance. It is part of the ongoing implementation of laws, ¹¹ and is usually one part of a broader compliance strategy. Enforcement activities are interrelated and usually commence when laws come into effect, or shortly after. ¹² This often requires the development of a clear enforcement program and strategy which sets out the actions required to secure compliance and support enforcement activities.

Enforcement includes prosecution of offences, but also includes other legal mechanisms to achieve compliance. Enforcement activities may encourage compliance with the law, as well as discourage breaches of the law through monitoring compliance and responding to violations.

Consistent and effective enforcement programs support public health outcomes and ensure that non- compliant persons and entities do not gain an unfair advantage over those who comply with the law. This ensures that all regulated persons and entities are treated equally. ¹³

Key regional and international frameworks

Several key instruments recognise the importance of compliance and enforcement with NCD laws. They provide technical guidance on the enactment and implementation of enforcement mechanisms, activities and programs at the country level, including in the Western Pacific Region and in low- resource settings.

Developing an effective enforcement program

Effective drafting of laws

Well-designed, comprehensive, and enforceable laws with clear and practical requirements, which grant necessary powers to authorised entities and persons (see the section on ‘What compliance and enforcement powers are needed’ below), are critical to ensuring compliance. Clearly defined rules, terms, appropriate sanctions, and evidence-based enforcement mechanisms impact compliance and enforcement, as does the robustness of the overall legal framework in which the law operates.

Box 2 sets out an example of how key terms are defined in Niue’s tobacco control legislation.

Consistency with other laws

NCD laws should be consistent with existing legal frameworks. This means that governments must respect constitutional rights, procedural obligations, and human rights obligations when developing and enforcing NCD laws. Unhealthy commodity industries may challenge the validity of NCD laws and related enforcement mechanisms based on trade or investment law, or on commercial rights which may be protected under constitutional or regional agreements, or on procedural grounds. To better protect legal measures against the risk of legal challenge, it is important to determine what other laws may be applicable, to follow due process in introducing or amending laws, and to consider how NCD laws may be enforced consistently with other obligations.

In addition, new NCD laws should be consistent with and complement other laws which address NCD risk factors. This includes existing laws which have been adopted in line with cost-effective policy interventions known as ‘Best Buys’ set out in Appendix 3 of the Global Action Plan for the Prevention and Control of NCDs 2013-2030. ²⁷

Governments must also ensure that enforcement mechanisms and activities are developed consistently with obligations arising under the WHO Framework Convention on Tobacco Control (WHO FCTC), ²⁸ and its Guidelines for Implementation. ²⁹ For example, when implementing article 8 of the WHO FCTC, governments must ensure that enforcement actions adequately protect people from exposure to tobacco smoke.

Who should be the subject of enforcement?

Laws and regulations target persons and entities which are required to comply with legal requirements. Where classes of persons and entities cannot be defined or are unknown, legislation may provide for broad application of laws and enforcement mechanisms.

Box 3 sets out various recommendations in the WHO FCTC Article 8 Guidelines for Implementation for imposing legal responsibility for smoke free laws.

Transitional periods

Legislation generally provides for a transitional period after it has come into effect to enable all regulated persons and entities to prepare for meeting their obligations under the new law before it is enforced. Where legislation does not provide for a transitional period, an initial fixed period of ‘soft enforcement’ may be outlined in the enforcement program.

Box 4 describes a transitional period under Australia’s tobacco plain packaging legislation.

Securing community, political and administrative buy-in

Clear and consistent communication is crucial to securing community buy-in and support for NCD laws. Communication increases public awareness and includes providing information on legal requirements to the public and regulated persons. Provision of information to unhealthy commodity industries should be in line with rules to prevent industry interference including Article 5.3 of the WHO FCTC which governs engagement with the tobacco industry.

Box 5 provides an example of a communications campaign in Chile designed to raise awareness of new legal requirements and mobilise civil society support.

 

It is also important to secure political and administrative buy-in. This can be achieved through sensitizing and making parliamentarians, policymakers, government officials, bureaucrats, technocrats and other officials across key sectors, as well as law enforcement authorities and agencies, whose support may affect compliance and enforcement, aware of NCD laws.

What are the key elements of an enforcement program?

Enforcement programs generally comprise a range of regulatory mechanisms and activities, and are governed by a clear compliance and enforcement strategy. The strategy outlines the objectives of the program, the strategic approach to achieving compliance, and the guiding principles which underpin the program. It usually employs a risk or harm-based approach to guide the use of compliance and enforcement mechanisms and activities available under the program, and in the legislation it works to enforce, in a graduated manner according to the gravity of the breach and level of potential risk or harm.

To what degree promoting compliance (e.g. educating the public and regulated entities), and/or monitoring compliance with the law (e.g. inspections, responding to violations), are used depends on the NCD risk factor being regulated, the local culture, the available resources, the persons and entities being regulated, and the nature and gravity of offences.

Promoting and monitoring compliance with the law

It is important to both promote and monitor compliance with the law. Promoting compliance involves informing regulated persons and entities about their obligations, duties, and what action will be taken in response to breaches. It also involves informing the public about what is prohibited, how to comply with the law, and how to report breaches. Providing technical assistance (e.g. expertise/ technology, training tools/materials) to regulated persons and entities, consistently with conflict of interest rules to protect from industry interference, supports implementation of legislation.

Monitoring whether regulated persons and entities are complying with the law, known as ‘compliance monitoring’, can help to identify violations and act as a deterrent.

Box 6 provides an example of technical guidance provided to regulated entities in Singapore to promote compliance with nutrition labelling laws.

 

Identifying violations

There are three common methods for identifying violations:

1. inspection and investigation
2. recordkeeping and reporting by regulated persons/entities
3. utilising a complaints system (e.g. for complaints from the public/civil society/ NGOs).

Inspection and investigation

Inspections and investigations are generally carried out by enforcement authorities and officers. Inspections may be conducted on a random or selective basis. Sampling and testing, a form of investigation, usually involves health authorities collecting and analysing product samples to determine compliance with standards.

Box 7 outlines an example of sampling and testing in Singapore to determine compliance with tobacco control laws which regulate the contents and emissions of tobacco products.

 

Recordkeeping and reporting

Reporting systems are a cost-effective way of identifying violations and promoting compliance. They require regulated persons and entities to retain compliance records and to disclose this information to enforcement agencies and other relevant government authorities. This may include information on product contents and ingredients, emissions, packaging/labelling, and marketing information. In some cases, regulated persons and entities may be required to arrange their own sampling and testing and to submit the results to the relevant authority.

Box 8 highlights an example from Niue where reporting requirements for tobacco product manufacturers and importers regularly require them to submit contents and emissions test results to health authorities.

 

Complaints system

Setting up a complaints system by which complaints from the public, civil society and NGOs can be reported, recorded and responded to by enforcement agencies is another method for identifying and deterring violations.

Box 9 describes a complaints system set up in Baguio City, Philippines for members of the public to report contraventions of smoke free laws.

 

What compliance and enforcement powers are needed?

Identifying and responding to violations is generally supported by legislation that grants adequate powers to enforcement agencies and officers to enforce the law.

Monitoring powers

Monitoring powers are typically used to determine whether a person is complying with the law, or whether information given under the law is accurate.

Monitoring powers allow enforcement authorities to carry out routine and targeted compliance activities including:

• entering and inspecting premises
• questioning
• obtaining and testing samples
• seizing unlawful products

Box 10 describes an example of powers used to monitor compliance with smoke free laws in China.

 

Investigation powers

Investigative powers enable enforcement authorities to investigate suspected breaches of the law and health risks. The objective of investigative powers is to gather evidence for compliance purposes. Investigative powers include:

• questioning, obtaining information, accessing records
• obtaining and testing samples
• inspection of documents, materials and products
• making recordings (e.g. video, photograph, audio)
• securing and operating equipment
• seizing unlawful products

Box 11 highlights an example of the seizure of unlawful products by enforcement authorities in Mexico.

 

Administrative compliance powers

Administrative compliance powers provide authorities with the power to take administrative actions when a person or entity fails to comply with a legal requirement or duty. Administrative actions may be taken by an authority without

initiating legal proceedings (such as civil or criminal action). These powers include:

• issuing formal warnings and compliance notices
• publicising instances of non-compliance
• issuing infringement notices
• refusing to issue licences or provide registration/ permit approvals
• placing a condition on licences/registration/ permits
• suspension or cancellation of licences/ registration/permits

Box 12 shows how administrative compliance powers have been used to address non-compliance with smoke free laws in Singapore.

 

Legal action and prosecution powers

Legal action and prosecution powers allow for persons who have contravened laws to be prosecuted where administrative action, such as issuing warning notices, has not achieved compliance. These powers are generally granted in legislation and include:

• imposing civil penalties (e.g. monetary penalties, fines)
• imposing criminal sanctions (e.g. monetary penalties, fines, imprisonment)
• corrective action (confiscation of products, imprisonment)
• arresting and prosecuting offenders

Box 13 sets out an example from Fiji in which tobacco control legislation grants legal action and prosecution powers to various persons.

 

Responding to violations

Once violations are identified, responding to contraventions of the law is necessary and acts as a deterrent by imposing sanctions for failure to comply with legal requirements. Appropriate severity of sanctions ensures that enforcement mechanisms have a deterring effect.

Responding to violations encompasses various mechanisms including:

• warnings and administrative orders (e.g. compliance notices, warning letters)
• sanctions and penalties (e.g. civil or criminal penalties, fines, infringement notices)
• licence, registration or permit suspension, revocation or cancellation
• legal action and prosecution

Warnings and administrative orders

Where a breach of a law or regulation has occurred, administrative compliance powers may be used to issue formal warnings and compliance notices which generally specify the violation, the provision of law which has been contravened, what the person or entity must do to return to compliance, the consequences of non-compliance (e.g. penalties/ sanctions), and the time within which compliance is required. The power to issue warnings may be contained in legislation or in the enforcement program, plan or non-legislative policy.

Box 14 sets out an example from Australia where the power to issue warnings is outlined in the national tobacco control enforcement policy, a non- legislative instrument.

 

Penalties and sanctions

Legislation generally prescribes penalties which may be imposed where administrative compliance powers, such as issuing warning letters or compliance notices, have not resulted in compliance. This includes civil penalties, such as fines or monetary penalties, as well as criminal penalties, such as fines, monetary penalties, and/ or imprisonment. For certain low-level violations, infringement notices, which are administrative in nature, may be issued by a regulatory or enforcement agency setting out the particulars of an alleged contravention of a civil penalty provision or a criminal offence. A person issued with an infringement notice may pay the amount specified in the notice to avoid further legal action.

Box 15 sets out several examples of penalties and sanctions for breaches of Tonga’s alcohol control legislation.

 

Box 16 describes an example from Samoa where legislation empowers police officers and alcohol inspectors to issue and serve infringement notices for certain breaches of the law.

 

Legal action and prosecution

Taking legal action and/or prosecuting offences and persons in contravention of laws or regulations may be necessary if compliance cannot be achieved through administrative compliance powers, and where no other appropriate remedies are available. This includes commencing legal proceedings to impose civil and criminal sanctions, prosecuting offences where there has been a failure to comply with an infringement notice, and defending legal challenges to uphold the validity of NCD legislation.

Box 17 describes an example of a government authority in Australia taking legal action against several tobacco retail companies which contravened consumer laws.

 

Licence suspension and cancellation

Temporary or permanent suspension of an entity’s licence may be necessary to protect public health, particularly where serious breaches of the law have occurred, or where civil and criminal sanctions have failed to secure compliance. Where temporary licence suspension fails to ultimately secure compliance or is inadequate due to the severity of the offence, revocation or permanent cancelation of the licence may be required. ⁷⁴

Box 18 outlines a legislative enforcement mechanism from Fiji which provides for licence suspension or revocation where certain tobacco control provisions are breached.

 

Who should be responsible for enforcement?

Legislation generally specifies which entities will be responsible for implementing and enforcing its provisions. Primary responsibility for enforcement and its coordination may be given to one entity or agency, however, other relevant enforcement agencies and government entities may also need to be involved to ensure a system- wide and whole-of-government approach to enforcement.

Legislation may devolve responsibility for enforcement on various governmental ministries, such as health, trade/commerce, justice, and finance, as well as on various national and local agencies. These may include prosecuting bodies, administrative bodies, taskforce committees, inter-ministerial committees, police, and judicial institutions. Legislation may also confer responsibility on public health inspectors, customs officers, transport officers, and other authorised officers, ⁷⁶ or provide responsible entities with authority to delegate responsibility for enforcement to individuals.

Box 19 provides an example from the Republic of Korea where officers, designated as ‘anti-smoking advisors’, are appointed by legislation to enforce smoke free laws.

 

Box 20 provides a further example from New Zealand where enforcement officers are appointed under legislation to monitor and enforce smoke free laws.

 

Enforcement of NCD laws commonly forms part of the mandate of subnational governments and local authorities which generally have greater familiarity with the local context and may have the necessary institutions, facilities and resources for enforcement.

Box 21 highlights an example from the Philippines where local authorities have primary responsibility for enforcement of smoke free laws.

 

Multisectoral coordination for enforcement

Multisectoral coordination and a whole-of- government and system-wide approach is critical to implementing an effective enforcement program. This may include establishing a multisectoral enforcement team, coordinating mechanism and/ or committee. ⁸⁴ Beyond coordinating enforcement activities, the mandate of a multisectoral body may also include protecting the enforcement of NCD laws from industry interference. The McCabe Centre for Law and Cancer explores multisectoral coordination further in its 2020 report on ‘Multisectoral coordination to address NCDs through law: Good practices from the Western Pacific Region’. ⁸⁵

Box 22 describes a multisectoral coordination mechanism established under alcohol control legislation in Thailand to enforce the provisions of the law.

 

Involving civil society and the public

Involving communities to enhance local support and increase awareness of NCD laws, as well as  encouraging the public to help enforce the law where appropriate, is important to promoting compliance. 

Civil society can influence social norms and has a central role in building support for NCD laws.

Civil society can support implementation of laws and regulations through educating the public and promoting sensitisation to secure community buy- in and counter opposition. Civil society, as well as NGOs and academic researchers can also contribute to implementation of laws and regulations through capacity building, advocacy, technical expertise and local knowledge. Members of the public and civil society may also assist with monitoring compliance with the law. This includes identifying violations and making complaints, exercising rights, and reporting on the effectiveness of enforcement activities.

Box 23 describes the work of the Cancer Society of New Zealand, a civil society organisation, in providing event organisers with guidance on enforcing smoke free laws.

 

Box 24 outlines the work of another civil society organisation, the Samoa Cancer Society, in supporting the implementation of NCD laws in Samoa.

 

How will the enforcement program be implemented?

A multisectoral coordinating mechanism, taskforce, team, or committee, comprised of key members of government agencies and civil society, should be responsible  for implementing the enforcement program to ensure policy coherence.

A system-wide approach to implementation and addressing industry interference is key, as well as effective resource planning, identifying enforcement priorities, and systemic capacity building and training at all levels of government and across sectors. Effective planning includes designing and coordinating a robust enforcement program underpinned by a clear compliance and enforcement strategy, activities, and accountability mechanisms to monitor and report on the progress of implementation and enforcement. The planning process should commence as early as possible and identify the need for conflict-of-interest policies to protect NCD laws and their implementation from industry interference.

Box 25 provides an example of ongoing enforcement planning activities in Palau.

 

Resourcing enforcement and other challenges

The resources available to implement and enforce NCD laws and regulations have a significant impact on compliance outcomes. This includes human, financial, technical and logistical resources that can be allocated to enforcement agencies, multisectoral coordinating mechanisms and taskforces. However, adequate and ongoing resources including those required for training officials are a challenge, particularly in low-resource settings, which has been further exacerbated by the COVID-19 pandemic due to the diversion of public resources. In some cases, monitoring and enforcement costs may be resourced through registration and licensing fees, or through taxes, duties, and levies (e.g. alcohol, tobacco, or sugar- sweetened beverage excise taxes), as well as by revenue from monetary penalties. Appropriate provisions for allocating resources should be included within relevant budgetary processes.

Other enforcement challenges, which may arise in both low and high-resource settings, include lack of coordination between critical sectors, lack of political will or commitment, poor civil society engagement, and industry interference. The NCD burden, the local context and the legal frameworks within which NCD laws operate also impact compliance. Multisectoral coordination, policy coherence, and a system-wide and equitable approach to enforcement are key to mitigating some of these challenges. Cooperation between national enforcement authorities and local authorities with knowledge of local factors is similarly critical.

Box 26 provides an example of national and local authorities being required by law to coordinate efforts on the enforcement of a healthy food procurement policy in the Philippines.

 

Monitoring and evaluation of the enforcement program

Regularly reviewing and monitoring the enforcement program is important to assessing its effectiveness. Monitoring and evaluation of the effectiveness of enforcement activities may be built into legislation to provide for monitoring bodies and periods of monitoring, and may be  undertaken by the multisectoral coordinating mechanism or an external independent agency.

Box 27 provides an example of a regional accountability mechanism for monitoring and reporting on progress on implementation and enforcement of NCD laws in the Pacific.

 

Multisectoral coordination and a whole-of- government approach facilitate effective enforcement. Local authorities are often well placed to enforce NCD laws and regulations (see Box 21), however, multisectoral coordination is crucial to ensuring an effective and whole- of-government approach to enforcement. The example from Thailand shows how a coordinating mechanism can be established by legislation to promote multisectoral coordination for enforcement of the law between various government agencies at the local and national level (see Box 22). The example from Quezon City, Philippines highlights the use of a governmental order requiring coordination between local and national authorities for the effective implementation of a healthy food procurement policy (see Box 26). Examples from New Zealand and Samoa show that involving civil society to implement NCD laws is also important (see Boxes 23 and 24). The example from Palau highlights the ongoing need for planning and coordinating implementation and enforcement activities (see Box 25). The MANA Dashboard example from the Pacific underscores the need to coordinate monitoring and evaluation of the implementation of NCD laws (see Box 27).

It is also important to reiterate the limitations of this report. The case studies described are not intended to be a comprehensive overview of how compliance and enforcement of laws for the prevention of NCDs can occur. Rather, these case studies are illustrative examples of how compliance and enforcement has been facilitated in different country contexts in the WHO Western Pacific Region and beyond. They do not reflect all examples of the effective enforcement of laws for NCD prevention within the region. In addition, the examples outlined in this report were largely obtained through secondary desk research with some exceptions, rather than through primary research methods. The case studies reflected in the report are also subject to sample and selection bias notwithstanding considerable efforts made to highlight the most relevant and useful available examples and to ensure accuracy of information.

Furthermore, legislative examples and legal mechanisms described in this report may not operate as they are envisaged or described in this report, or their implementation may have changed over time. Challenges to compliance and enforcement have not been addressed in detail in this report, but it is important to highlight that even where the above lessons are considered, contextual factors such as political will, available resources, effective governance, legal frameworks, and the judicial system can all impact compliance and the effectiveness of enforcement.

With those limitations in mind, the case studies and lessons from this report are intended to encourage ideas and discussion on promoting compliance and effective enforcement for NCD prevention across the Member States and areas in the Western Pacific Region.

References

[1] ‘Noncommunicable diseases in the Western Pacific’, World Health Organisation Regional Office for the Western Pacific (Web Page) < https://www.who.int/westernpacific/health-topics/noncommunicable-diseases>.

[2] ‘Noncommunicable Diseases’, World Health Organisation (Web Page) < https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases>.

[3] Noncommunicable diseases in the Western Pacific (n 1).

[4] Noncommunicable Diseases (n 2).

[5] World Health Organisation, Global Action Plan for the Prevention and Control of Noncommunicable diseases 2013-2020 (2013) (‘Global Action Plan for NCDs’) < https://www.who.int/publications/i/item/9789241506236>.

[6] World Health Organisation, Information note on COVID-19 and NCDs (Report, 23 March 2020) < https://www.who.int/publications/m/item/covid-19-and-ncds>.

[7] NCD Alliance, Signalling Virtue, Promoting Harm (Report, September 2020) 4-5 < https://ncdalliance.org/resources/signalling-virtue-promoting-harm>.

[8] Ibid 16.

[9] Ibid 11-12.

[10] Ibid 29-30.

[11] World Health Organisation Regional Office for Africa, Enforcement of and Compliance with Tobacco Control Legislation: A Guide for the WHO African Region (2016) (‘Enforcement Guide for the WHO African Region’) 3 < https://www.afro.who.int/sites/default/files/2017-06/enforcement-of-and-compliance-with-tobacco-control-legislation---a-guide-forthe-african-region.pdf>.

[12] Ibid.

[13] Ibid 4.

[14] World Health Organisation Regional Office for the Western Pacific, Better laws for better health: Western Pacific regional action agenda on strengthening legal frameworks for health in the Sustainable Development Goals (2020) (‘Western Pacific Regional Action Agenda’) < https://apps.who.int/iris/handle/10665/331910>.

[15] Ibid vi.

[16] Global Action Plan for NCDs (n 5); Follow-up to the Political Declaration of the Third High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases, WHA Dec 72(11), 72nd sess, 7th plen mtg, agenda item 11.8, WHA Doc WHA72(11) (28 May 2019) (‘Decision WHA Dec 72(11)’) [2].

[17] Global Action Plan for NCDs (n 5).

[18] World Health Organisation Framework Convention on Tobacco Control, opened for signature 21 May 2003, 2302 UNTS 166 (entered into force 27 February 2005) (‘WHO FCTC’); WHO FCTC Conference of the Parties, Guidelines for Implementation of the World Health Organisation Framework Convention on Tobacco Control (2013) (‘Guidelines for Implementation’) < https://apps.who.int/iris/bitstream/handle/10665/80510/9789241505185_eng.pdf?sequence=1&isAllowed=y>.

[19] World Health Organisation Regional Office for the Western Pacific, Regional action plan for tobacco control in the Western Pacific (2020- 2030): Working towards a healthy, tobacco-free (April 2020) < https://www.who.int/publications/i/item/9789290619062>.

[20] World Health Organisation Regional Office for the Western Pacific, Addressing the harmful use of alcohol: A guide to developing effective alcohol legislation (December 2013) < https://www.who.int/publications/i/item/9789290615033>.

[21] World Health Organisation, Global Strategy to Reduce the Harmful use of Alcohol (2010) < https://www.who.int/publications/i/item/9789241599931>.

[22] World Health Organisation Regional Office for the Western Pacific, Regional action framework on protecting children from the harmful impact of food marketing in the Western Pacific (April 2020) < https://www.who.int/publications/i/item/9789290619093>.

[23] World Bank, Non-communicable Disease Roadmap Report (Report, 2014) < https://documents1worldbank.org/curated/en/534551468332387599/pdf/893050WP0P13040PUBLIC00NCD0Roadmap.pdf>.

[24] Ibid.

[25] World Health Organisation Regional Office for the Western Pacific, For the Future: Delivering Better Health in the Western Pacific Region (White Paper, April 2019) < https://www.who.int/docs/default-source/inaugural-who-partners-forum/white-paper.pdf?sfvrsn=86afc1fb_0>.

[26] Tobacco Control Act 2018 (Niue) s 4.

[27] Global Action Plan for NCDs (n 5); World Health Organisation, Tackling NCDs: ‘best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases (‘Updated Appendix 3’) (2017) < https://apps.who.int/iris/handle/10665/259232>; Decision WHA Dec 72(11) (n 16).

[28] WHO FCTC (n 18).

[29] Guidelines for Implementation of the WHO FCTC (n 18).

[30] Guidelines for Implementation of the WHO FCTC (n 18).

[31] Tobacco Plain Packaging Act 2011 (Australia) s 2.

[32] Ibid.

[33] World Health Organisation, Implementing nutrition labelling policies: A review of contextual factors (Report, September 2021) < https://www.who.int/publications/i/item/9789240035089>.

[34] Singapore Food Agency, A Guide to Food Labelling and Advertisements (September 2021) 39-41 < https://www.sfa.gov.sg/docs/default-source/food-information/labelling-and-packaging-information/a-guide-to- food-labelling-and-advertisements.pdf>.

[35] Singapore Health Promotion Board, A Handbook on Nutrition Labelling

[36] (June 2020) 5-9 < https://www.hpb.gov.sg/docs/default-source/newsroom/a-handbook-on-nutrition-labelling-(singapore)-_june-2020.pdf?sfvrsn=b232e5ec_2>.

[37] Singapore Ministry of Health, Supporting Singaporeans to care for their health and wellbeing (Fact Sheet, 2020) < https://www.moh.gov.sg/docs/librariesprovider5/cos2020/cos-2020---supporting-singaporeans-to-care-for-their-health-and-wellbeing.pdf>; ‘Mandatory Nutrition Labelling and Advertising Prohibitions for ‘Nutri-Grade’ Beverages from 30 December 2022’, Singapore Ministry of Health (Web Page, 30 December 2021) < https://www.moh.gov.sg/news-highlights/details/mandatory-nutrition-labelling-and-advertising-prohibitions-for-nutri-grade-beverages-from-30-december-2022#:~:text=%5B1%5D%20%E2%80%9CNutri%2DGrade,beverage%20that%20is%20prepared%20by>.

[38] Singapore Health Promotion Board, Labelling and advertising requirements for Nutri-grade beverages sold in Singapore (2021) < https://hpb.gov.sg/docs/default-source/pdf/industry-guidance-document.pdf?sfvrsn=5ae8a24c_4>; ‘Measures for Nutri-grade Beverages’, Singapore Health Promotion Board (Web Page) < https://www.hpb.gov.sg/healthy-living/food-beverage/nutri-grade#resources>.

[39] ‘HSA Cigarette Testing Laboratory Designated a World Health Organisation Collaborating Centre for Tobacco Testing and Research’, Singapore Health Sciences Authority (Web Page) < https://www.hsa.gov.sg/announcements/news/hsa-cigarette-testing-laboratory-designated-a-world-health-organisation-collaborating-centre-for-tobacco-testing-and-research>.

[40] World Health Organisation, Tobacco product regulation: Building laboratory testing capacity (2018) 40 < https://apps.who.int/iris/bitstream/handle/10665/260418/9789241550246-eng.pdf>.

[41] ‘Cigarette Testing Laboratory Test Request and Acknowledgement Form’, Singapore Health Sciences Authority (Web Page) < https://form.gov.sg/#!/5dfb3e1bdf378700118e5c9a>.

[42] Tobacco Control Act 2018 (Niue) s 34.

[43] Ibid s 34(1)(a).

[44] Ibid s 34(1)(b).

[45] Tobacco Control Regulations 2020 (Niue) s 6.

[46] Ibid s 6(2)(c).

[47] Tobacco Control Act 2018 (Niue) s 35.

[48] ‘About Smoke-Free Baguio’, Smoke-Free Baguio (Web Page) <https:// smokefreebaguio.wordpress.com/about/>.

[49] Ibid.

[50] ‘Report Violations’, Smoke-Free Baguio (Web Page) < https://50.smokefreebaguio.wordpress.com/report/>.

[51] ‘Honours for tobacco control in WHO Western Pacific Region’, World Health Organisation Regional Office for the Western Pacific (Web Page, 30 May 2019) < https://www.who.int/westernpacific/news/item/30-05-2019-honours-for-tobacco-control-in-who-western-pacific-region>.

[52] Ibid.

[53] Ibid; ‘Xi’an’s strong, new smoke-free law will protect 12 million citizens’, Vital Strategies (Web Page, 1 November 2018) < https://www.vitalstrategies.org/xians-strong-new-smoke-free-law-will-protect-12-million-citizens/>.

[54] ‘Mexico seizes 380,000 boxes of Kellogg’s cereal’, Associated Press (Web Page, 15 January 2022) < https://apnews.com/article/business-lifestyle-mexico-caribbean-mexico-city-afb31c1a066a20f65bb8b1b54521da37?mkt_tok=Njg1LUtCTC03NjUAAAGCNeAsf5akaEs1MoJUyQgT2nQGdaff6AYDi2bgT7TraK_-m9SNPbD21ixE_TLEaIvY38jeSy6NlVuNFeZMhIzsI0lcaRaaVsbtGrs2RY4gzSM8og>.

[55] Regulation of the General Health Law on Advertising 2000 (as amended) (Mexico) art 24 Bis 1.

[56] Regulation of Sanitary Control of Products and Services 1999 (as amended) (Mexico).

[57] Smoking (Prohibition in Certain Places) Act (Cap. 310) (as amended) (Singapore) s 3(2).

[58] ‘One-Year Update on Orchard Road No Smoking Zone’, National Environment Agency (Singapore) (Web Page, 17 January 2020) < https://www.nea.gov.sg/media/news/news/index/one-year-update-on-orchard-road-no-smoking-zone>.

[59] Tobacco Control Decree 2010 (Fiji) s 37(1).

[60] Department of Health and Aged Care – Australian Government, Tobacco Control Enforcement Policy (January 2022) 10 < https://www.health.gov.au/resources/publications/tobacco-control-enforcement-policy>.

[61] Ibid.

[62] Intoxicating Liquor Act 2016 (Tonga) s 57.

[63] Ibid s 94.

[64] Ibid ss 98-99.

[65] Ibid s 101.

[66] Ibid s 102.

[67] Alcohol Control Act 2020 (Samoa) s 63.

[68] Ibid s 16(2).

[69] ‘ACCC takes action against the Joystick company for alleged misleading e-cigarette “no toxic chemicals” claims’, Australian Competition & Consumer Commission (Web Page, 9 September 2016) (‘ACCC takes action against Joystick’) < https://www.accc.gov.au/media-release/accc-takes-action-against-the-joystick-company-for-alleged-misleading-e-cigarette-%E2%80%9Cno-toxic-chemicals%E2%80%9D-claims>; Australian Competition and Consumer Commission v The Joystick Company Pty Ltd [2017] FCA 397 (‘ACCC v Joystick’).

[70] ‘E-cigarette companies to pay penalties’, Australian Competition & Consumer Commission (Web Page, 8 May 2017) < https://www.accc.gov.au/media-release/e-cigarette-companies-to-pay-penalties>.

[71] ACCC takes action against Joystick (n 69).

[72] Australian Competition and Consumer Commission v Social-Lites Pty Ltd (‘ACCC v Social-Lites’) [2017] FCA 398; Australian Competition and Consumer Commission v Burden [2017] FCA 399 (‘ACCC v Burden’).

[73] ACCC v Joystick (n 69); ACCC v Social-Lites (n 72); ACCC v Burden (n 72).

[74] Ian Ayres and John Braithwaite, Responsive Regulation: Transcending the Deregulation Debate (Oxford University Press 1992) 35-36.

[75] Tobacco Control Regulations 2012 (Fiji) r 27(1)(b).

[76] Enforcement Guide for the WHO African Region (n 11) 14.

[77] National Health Promotion Act 2017 (Republic of Korea).

[78] Ibid arts 9-5(1).

[79] Ibid arts 9-5(2).

[80] Ministry of Health (New Zealand), Smokefree Aotearoa 2025 Action Plan - Auahi Kore Aotearoa Mahere Rautaki 2025 (9 December 2021) 26 < https://www.health.govt.nz/publication/smokefree-aotearoa-2025-action-plan-auahi-kore-aotearoa-mahere-rautaki-2025>.

[81] Smokefree Environments and Regulated Products Act 1990 (New Zealand) s 91.

[82] Tobacco Regulation Act 2003 (Republic Act No. 9211) (Philippines); Local Government Code of 1991 (Republic Act No. 7160) (Philippines); National Tobacco Control Strategy 2017-2022 (Philippines) (‘The Philippines’ National Tobacco Control Strategy’) < https://theunion.org/sites/default/files/2022-03/Philippines NTCS 2017 - 2022.pdf>.

[83] The Philippines’ National Tobacco Control Strategy (n 82) 28-29.

[84] Enforcement Guide for the WHO African Region (n 11) 20.

[85] McCabe Centre for Law and Cancer, Multisectoral coordination to address NCDs through law: Good practices from the Western Pacific Region (Report, 2020) < https://www.mccabecentre.org/publications/multisectoral-coordination-to-address-ncds-through-law-good-practices.html>.

[86] Alcoholic Beverage Control Act 2008 (Thailand) s 5.

[87] Ibid s 8.

[88] World Health Organisation Regional Office for South-East Asia, Alcohol Policy in the WHO South-East Asia Region: A Report (Report, 2017) < https://apps.who.int/iris/rest/bitstreams/1093193/retrieve>.

[89] Alcoholic Beverage Control Act 2008 (Thailand) s 10.

[90] Ibid s 16.

[91] Ibid ss 18-19.

[92] Ibid s 22.

[93] Ibid s 24.

[94] Ibid s 25.

[95] Cancer Society New Zealand (Auckland Division), Smokefree Events- tips for implementation (2022) < https://www.cancer.org.nz/assets/smokefree/Guide-for-smokefree-events.pdf>.

[96] Ibid 3.

[97] ‘Six organisations are recognized for their tobacco control contributions in the Western Pacific Region’, World Health Organisation Regional Office for the Western Pacific (Web Page, 3 June 2021) (‘Organisations recognized for tobacco control in the Western Pacific Region’) < https://www.who.int/westernpacific/news-room/feature-stories/item/six-organisations-are-recognized-for-their-tobacco-control-contributions-in-the-western-pacific-region>.

[98] ‘Science Fair marks No Tobacco Day’, Samoa Observer (Web Page, 5 June 2021) < https://www.samoaobserver.ws/category/samoa/85173>; ‘UICC members and Past President recognised for their work in tobacco control’, Union for International Cancer Control (UICC) (Web Page, 22 June 2021) < https://www.uicc.org/news/uicc-members-and-past-president-recognised-their-work-tobacco-control>.

[99] Organisations recognized for tobacco control in the Western Pacific Region (n 99).

[100] Tobacco Control Amendment Act 2019 (Samoa) item 3, s 7A.

[101] Ibid item 3, ss 7A, 7C.

[102] Ibid item 3, s 7B.

[103] Executive Order No. 379 2015 (Palau) cl (a).

[104] Republic of Palau Non-communicable Disease Prevention and Control Strategic Plan of Action (2015-2020) 20 < https://www.palauhealth.org/files/FinalDraft-PalauNCDPlan_complete%20pages-dc%20(Low%20Res).pdf>.

[105] Ibid 19.

[106] Quezon City Executive Order No. 16, Series of 2021 (Philippines).

[107] Ibid s 10.

[108] ‘Pacific Monitoring Alliance for NCD Action (MANA Dashboard)’, Pacific Data Hub (Web Page) < https://www.pacificdata.org/dashboard/health-dashboard/enforcement>.

[109] Western Pacific Regional Action Agenda (n 14) vi.