Author: Clare Slattery et al
Published in: Health Promotion International
Published by: Oxford University Press
Date: May 2025

Harnessing law for global noncommunicable disease control: evaluating a legal training program, 2014-2023

Abstract

In 2014, the McCabe Centre for Law & Cancer launched its flagship International Legal Training Programme (ILTP), which aims to raise the capacity of government lawyers from low- and middle-income countries using the law to address noncommunicable diseases (NCDs). The course consisted of in-person/online training followed by practical implementation by participants through a “priority project”. To evaluate the ILTP, we conducted a mixed-methods study using: 1) pre- and post-course survey data collected from participants over the last 10 years; 2) assessment of legal and policy changes made by participants in their home countries following the ILTP; and 3) assessment of outcomes reported publicly. From 2014-2023, the ILTP had 450 participants from 97 countries and territories over its 13 deliveries. Participants rated the ILTP highly and reported large increases in confidence/knowledge in using law for NCD prevention and control. Priority projects developed by participants contributed to NCD law and policy change in a documented 30 countries, the defence of legal challenges to NCD laws in five countries, and the initiation of a legal challenge against the tobacco industry to recover health care costs in one country. Evaluation of the ILTP reveals that building the capacity of government lawyers can be effective in driving legal and policy change to better prevent and control NCDs globally. Legal capacity building programs such as the ILTP are essential for addressing NCDs and must be continued and expanded.

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Introduction

Noncommunicable diseases (NCDs) are the world’s leading cause of death and disease (WHO, 2024a). Laws targeting key NCD risk factors—including tobacco, alcohol and unhealthy diet—are cost-effective ways to limit the effects of these diseases (Magnusson et al., 2018; WHO, 2024b). Law effectively targets the now widely recognised problem of the commercial determinants of health (Mialon, 2020). Yet globally, law remains an underused tool for NCD prevention and control (Magnusson et al., 2018). Moreover, the challenges in curtailing the harms caused by transnational corporations trading in such products is significantly more challenging in low- and middle-income countries, which suffer at least 70 per cent of the global burden of NCDs (WHO, 2024a).

Building the capacity of lawyers and policymakers in low- and middle-income countries to better use the law is therefore a valuable avenue for reducing the global burden of NCDs (Magnusson et al., 2018). The McCabe Centre for Law & Cancer (McCabe Centre) was established in 2012 due to recognition of the critical role of law and policy in addressing NCDs. It was named for Rolah McCabe who, in suing British American Tobacco for causing her lung cancer, became the first person outside the United States to win a verdict against Big Tobacco in a personal injury claim. The McCabe family and lawyers then donated part of the settlement funds towards establishing a specialist legal centre to continue similar efforts.

Shortly after its founding, the McCabe Centre sought to help fill the global gap in legal and policy capacity for the prevention and control of NCDs by launching the International Legal Training Programme (ILTP). This program was developed in 2013 and launched in 2014. It was primarily conceived of as a support for government lawyers and policymakers in low- and middle-income countries who were seeking to use the law for NCD prevention and control. Consequently, participants were introduced to applicable legal frameworks on NCDs and related fields, including sustainable development, human rights at the international level, and targeted training on related aspects of trade and investment law. They were also to be given instruction on supporting the exchange of information between countries on legislation and litigation. A key goal of the course was supporting countries to respond to legal challenges by transnational unhealthy commodities companies. Early courses had a significant focus on policy coherence and multisectoral collaboration between health, trade, and investment law in the context of legal challenges to tobacco control laws, with the course over time becoming more a general exploration of implementing laws and policies to prevent and control NCDs. Since its launch, the ILTP has run 13 times and has in turn provided training to 450 participants from 97 countries and territories.

This article describes the ILTP and evaluates how it has met its aim of building capacity in NCD prevention and control. We assess changes in participants’ reported perceptions of their own abilities to use the law, and also describe changes to NCD laws and policies in low- and middle-income countries that have in some measure resulted from the course. To do so, we undertook a mixed-methods study using historic evaluation data from pre- and post-course surveys, and publicly available information on laws and policy, based on four metrics: 1) participants’ reported satisfaction; 2) reported changes in confidence/knowledge in using law for NCDs; 3) the ILTP’s documented and/or reported contribution to the adoption, implementation, enforcement or defence of NCD laws or policies; and 4) the ILTP’s documented impact on broader awareness of and support of using law to address NCDs.

Background

The McCabe Centre has run many trainings and workshops on law and NCDs since its founding in 2012, including as part of its role as the WHO Collaborating Centre on Law and Noncommunicable Disease (since 2018) and as the WHO Framework Convention on Tobacco Control (WHO FCTC) Knowledge Hub on Legal Challenges (since 2013). This article focuses on the ILTP, which specifically aimed to build legal capacity of government lawyers and policymakers from low- and middle-income countries. From 2014 to 2019, it ran as a multiweek face-to-face (F2F) course, in Melbourne, Australia (deliveries 1-9). The ILTP was moved online from 2020 due to the COVID-19 pandemic (deliveries 10-13).

Between 2014 and 2023, 450 participants from 97 countries and territories enrolled in the ILTP, and 345 completed (see Tables 1 and 2) (These figures include a small number who participated on multiple occasions). Participants came from all WHO Regions, with the most coming from the WHO’s Western Pacific, Africa, and South-East Asia Regions. Participants were primarily government officials, although some came from non-government organisations (e.g. not-for-profits and academia) and inter-governmental organisations (e.g. WHO country offices). Selection was by the McCabe Centre in coordination with relevant stakeholders including WHO Headquarters, Regional and Country Offices; the WHO FCTC Secretariat; and the Secretariat of the Pacific Community (SPC). For the F2F deliveries, nominations were made from relevant country focal points via stakeholders. For online deliveries, they were made directly via an online form.

The direct costs of the course were primarily funded by the Australian Government, with staffing costs primarily covered by the McCabe Centre’s parent body, Cancer Council Victoria. Some participants received other funding, with a small number—particularly from high-income countries—funded by their home governments or institutions.

Course content was adapted to participants’ and countries’ needs and interests but focused on a consistent set of objectives and core topics. These included tobacco control—especially, the key provisions of the WHO FCTC—alcohol control, healthy diet and physical inactivity, international trade and investment law, and overarching issues of human rights law, sustainable development, policy coherence, and multisectoral coordination. Courses also at times covered a range of other topics. These included, domestic legal challenges to NCD measures; occupational and environmental cancers; universal health care coverage; access to medicines; negotiating trade and investment agreements; lessons for policy development and implementation, and enforcement in low-resource settings. In recent years, air pollution was included in the program due to global recognition that it is a major NCD risk factor (Campbell-Lendrum and Prüss-Ustün, 2019). An example of the agenda for an in-person course is contained in Appendix 1.

There were substantial differences in approach between the F2F and online deliveries. F2F used presentations, individual and group activities (such as moot court exercises), and one-on-one sessions with McCabe Centre staff, initially delivered intensively over four weeks for delivery 1, and subsequently over three weeks. Online deliveries used seven self-paced modules comprising recorded presentations, quizzes, activities, and discussion forums, delivered over a six- to eight- week period. Asynchronous activities were supported by live video-meetings scheduled to accommodate multiple time zones.

ILTP facilitators were staff from the McCabe Centre and Cancer Council Victoria; McCabe Centre Regional Managers (consultants based in-region in Africa, Asia, and the Pacific); and university academics. Stakeholders also attended and actively participated, including representatives of the WHO FCTC Secretariat, WHO Regional Offices, the SPC, and the Australian Government.

In each F2F delivery, participants started a “priority project” that consisted of addressing a legal or policy challenge of importance to their role and/or jurisdiction. Each participant selected their project in consultation with colleagues and developed it during the course with guidance from the instructors. These projects were then completed on return home after the course with continuing support provided by McCabe Centre Regional Managers. These projects were removed from the curriculum when the course transitioned to online delivery for course 10 because of insufficient capacity to provide instructor- or peer-support in the new mode of delivery. For courses 12 and 13, however, a smaller version of this project was trialled. 

Methods

This study is a retrospective evaluation of the ILTP based on quantitative and qualitative data collected incidentally during its deliveries. Because these data were not collected from the outset with research in mind, they have certain limitations that the research team have been required to accommodate. The data come from three sources:

1) Quantitative data on demographics, and participation satisfaction and confidence, collected from pre- and post-course surveys conducted for stakeholder reporting and iterative course development;

2) participant reports to the McCabe Centre staff of outcomes of projects developed during the course; and

3) assessment of publicly reported outcomes of the ILTP and “priority projects” begun by participants during the course.

Survey data

Pre- and post- surveys were conducted from deliveries 3 to 13 to determine participant satisfaction and increases in confidence/knowledge using law to address NCDs. Surveys were completed online prior to commencing the F2F deliveries and at the start of online courses. Post-surveys were completed on the last day of the F2F deliveries (3-9), and for online deliveries, after all seven modules were completed (10-13).

Across all deliveries:

• 332 participants completed a pre-course survey.
• 287 participants from 296 who completed a course returned a survey (97%).

Because these surveys were not designed with a later study in mind, they varied in wording and in the number of questions asked. However, all of the surveys for courses 3 to 13 included questions using a Likert scale and space for open-ended feedback. To ensure comparative analyses could be conducted, the following decisions were made about the quantitative data:

• Across all the surveys, two of the questions addressed overall participation satisfaction with the courses and were selected for this evaluation.
• Depending on the course, six- to eight questions assessed confidence in key skills before and after the F2F course. The exact wording of the questions varied over time due to the changing context of the course. For example, some courses assessed confidence relating to the role of law in reducing the burden caused by NCD risk factors beyond tobacco, such as alcohol and unhealthy diet, however, this was not consistently assessed across all F2F courses. To account for these variations in wording yet consistent meaning, six key skills were considered. (To avoid confusion, the most frequently used wording is reflected in the results.)
• Questions on confidence in key skills that were not consistently asked across the F2F courses and where the wording varied significantly were excluded.
• The surveys for the online course consistently compared knowledge in nine key skills both before and after delivery and had only minor variations in the wording of the questions. As a result, all nine questions were included in this study.
• Basic demographic data was also collected in these surveys, including country of origin, gender, and professional role. These data were analysed to understand the character of the participant cohorts that attended each course delivery and changes in participation over time. De-identified data on country of origin, number of participants who came from each WHO regions, and the corresponding country income levels (2014-2023) was collected and is presented below in Tables 1 and 2.
• Qualitative survey data
• Beyond the quantitative data, the surveys also yielded some qualitative data about participant experiences. Open-ended questions for F2F and online deliveries generally allowed participants to provide comments. These largely included discussions of what they found most valuable; how they intended to use their knowledge; and suggestions for course improvement. The questions varied significantly in wording, however, limiting the utility of these responses in this case. Examples of the questions and their variation is provided in Appendix 2 (F2F delivery) and Appendix 3 (online delivery). Consequently, only comments that spoke to the overall impact of the course were collated and used in this study.

Follow-up on participants’ priority project outcomes

For courses 1-9, the McCabe Centre conducted formal follow-up with participants six months after the course to assess the progress of their priority projects to determine effects on laws or policies. Information on the success of these projects was also gleaned from informal reporting by participants to the McCabe Centre. This follow-up occurred via email, phone calls, or text messages, depending on the preference and location of the participant. Platforms like WhatsApp were commonly used. Informal priority project follow-up does not have a defined end date, with participants regularly reporting updates on their projects many years after completing the course. Participants also continue to regularly provide updates about their priority projects and new work that relates to the education provided by the ILTP.

Where possible, these informal reports by participants were confirmed by McCabe Centre staff against publicly available information. For example, claims that a law had been passed would be verified by checking relevant legislative databases in the country and/or the Campaign for Tobacco-Free Kids’ Tobacco Control Laws website (www.tobaccocontrollaws.org) for a copy or reference to the law, or by searching for policy announcements from official sources. In some cases, verification involved reaching out to stakeholders or other alumni working in the country or region to verify the status of laws due to challenges publicly accessing laws in many countries. Where verification was not possible (for example because the project was an internal policy or event and not of a public nature), participant claims were generally accepted as reported.

Database searches to assess the impact of the ILTP

To capture further insight into the broader impact of the ILTP, online archives and published materials were systematically searched. Databases included, WHO IRIS; websites of the SPC, Australian Government and Pacific Islands Forum; and the UN High Level Political Forum. Search terms used were “ILTP” (and its full spelling); “Legal Training”; “McCabe Centre”; and “Knowledge Hub”. Only direct references to the ILTP were collected and reported.

Results

Course participation and completion

450 participants from 97 countries and territories participated in the ILTP, with 92% from low- or middle-income countries and 8% from high income countries.

The character of the cohort changed over time. Deliveries 1 to 13 varied in size from 14 to 89 participants, with the move online dramatically increasing enrolments from an average of 20 participants to 69. Virtually 100% of participants completed the F2F courses. However, online courses had lower completion rates, ranging from 48% to 75% (2023/2022), where completion was defined as completing all seven modules.

Over the 13 courses, 53% of participants were female versus 47% males, mirroring closely course completions: 54% female, 46% male. Female participation increased from 51% F2F to 55% for online enrolments (57% for completions). Gender for F2F was obtained from travel documents, for online deliveries participants were asked their gender with options including self-identify and prefer not to specify.

Conclusions and future directions

From 2014 to 2023, the ILTP had 450 participants from 97 countries and territories, and meaningfully helped build capacity in the use of law for NCD prevention and control. Evaluation of the ILTP reveals the power and potential to affect change from building legal capacity in the prevention and control of NCDs. Despite the relatively modest size of the program, participants significantly increased their confidence/knowledge in key skills and contributed to significant new NCD laws and policies, the defence of legal challenges, and the recovery of health care costs. This evaluation makes a compelling case for investing in legal training programmes aimed at raising the capacity of lawyers in addressing NCDs using law and policy.

The transition of the course from F2F to online delivery also provides lessons in how to make an intensive, networking-focused course work in a digital medium. Finally, the counting of completed priority projects only captures part of the impact of the ILTP. A second study using qualitative interviews with alumni and stakeholders of the course is underway to provide a fuller picture of the impact of the ILTP and ongoing needs in relation to legal capacity. It is clear at this point, however, that the development of a network of alumni with legal skills through the ILTP has helped countries use law to reduce the burden of NCDs around the world.

References