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Abstract
Background Namibia is typical of low-income and middle-income countries with growing tobacco use, but with limited capacity to impose comprehensive tobacco control legislation. Despite initiating dialogue on national tobacco control policy in 1991, the country took nearly 20 years to pass the Tobacco Products Control Act.
Objective To use Namibia as a case study to illustrate challenges faced by low-income countries working to forward tobacco control legislation.
Method Face-to-face and telephonic interviews were conducted with 13 bureaucrats and advocates currently or previously engaged in tobacco-related work in Namibia. Tobacco-related news articles from national newspapers were examined.
Results The constitutional obligation of the government to promote public health laid the foundation for Namibia's tobacco control policy. Staff capacity constraints greatly delayed the passing of tobacco control legislation. It is unclear what influence the tobacco industry's involvement as a stakeholder had on policy; however, in at least one instance, the tobacco industry actively misled government. Namibia's ratification of the Framework Convention on Tobacco Control was instrumental in passing legislation that meets most provisions of the international treaty. The media have generally played a supportive role in pushing the government to pass tobacco control legislation.
Conclusions The fact that Namibia was able to pass fairly comprehensive tobacco control legislation with such meagre resources is commendable. The government must now implement the regulations that make the legislation effective. Tobacco control progress in low-income and middle-income nations can be encouraged through use of the media and improved staff and legal capacity within health ministries.
- Low/Middle income country
- Advocacy
- Media
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Background
While tobacco consumption in Sub-Saharan Africa is low compared with other parts of the world, researchers’ projections indicate a dramatic escalation in coming decades.1 ,2 Tobacco companies have been aggressively promoting their products in African nations, where tobacco control legislation is often weak or nonexistent.3 Furthermore, in recent decades, Africa has been experiencing rapid economic growth, and the resulting increases in income have made tobacco more affordable to the population.4 Across the continent, health advocates and government officials are working to implement comprehensive tobacco control legislation in order to prevent an expanded tobacco-related disease burden.
Like many African countries, Namibia is still in the early stages of the tobacco epidemic, and can prevent much of the premature death and morbidity if it takes action now. In 2007, Namibia's Demographic and Health Survey reported 21% of men and 5% of women aged 15–49 were current cigarette smokers.5
With 2.3 million people living in a country twice the size of Germany, Namibia is a sparsely populated African nation. A former German colony, South-West Africa became an administrative region of South Africa in 1919 and gained independence in 1990, officially changing its name to Namibia. The World Bank reclassified Namibia from a lower middle-income country to a higher middle-income country in 2011.6 This recent increase in average income hides the fact that Namibia has the most unequal recorded distribution of income in the world.7
The Tobacco Products Control Act of Namibia had its genesis in 1991, was publicly announced in 1998, and eventually passed in 2010 despite delays and sporadic interference by the tobacco industry. Namibia signed the World Health Organisation's Framework Convention on Tobacco Control (WHO FCTC) in January 2004 and ratified it in November 2005.8 After nearly two decades of effort, the country was able to pass comprehensive tobacco control legislation in line with many provisions of the FCTC. At the time of writing (January 2013) the country still needs to finalise the regulations that give effect to the legislation.
The Namibian experience may reflect some of the challenges faced by low-income and middle-income countries that want to enact effective tobacco control legislation. Understanding the factors that allow these nations to succeed in furthering tobacco control can inform advocacy efforts around the world. The following case study of Namibia offers lessons that carry the potential to drive such progress, especially for other low-income and middle-income countries that wish to learn from the achievements and setbacks of a nation with similar constraints.
Methods
Semi-structured, face-to-face and phone interviews were conducted from June to August 2011 with 13 individuals including: bureaucrats from the Ministry of Health (2), Ministry of Safety and Security (1), Ministry of Finance (2), the Central Bureau of Statistics (1), the South African Ministry of Health (1), the Cancer Association of Namibia (2) and community health workers at Blue Cross Namibia (4). Individuals were identified through snowball sampling or through direct inquiry to the relevant government ministry. While questions were adapted to ensure appropriateness for the interviewee, individuals were asked probing questions about (1) their knowledge of tobacco issues in the country, (2) their degree of involvement in tobacco-related regulation, (3) their observations about the process of passing or implementing tobacco control legislation and (4) their thoughts about what factors influenced tobacco policy outcomes. Interview data were used to construct a narrative of tobacco control and evolving conditions surrounding tobacco legislation over time. Key variables influencing policy outcomes were identified as those most frequently mentioned or discussed at greatest length. These were combined with data from news media to form the major themes guiding the structure of the paper. Follow-up interviews were also conducted to confirm and cross-reference information collected. All participants were interviewed in their professional capacities regarding non-sensitive information. This study received an exemption from the University of Michigan Institutional Review Board and approval from Namibia's Ministry of Health and Social Services Ethics Review Board.
Tobacco control issues were also examined from the perspective of news media; 764 English language newspaper articles from 1980 to 2012 were identified through LexisNexis Academic using search terms ‘Namibia’ and ‘tobacco’ or ‘smoking’. English is the official language of the country; newspapers publishing exclusively in Afrikaans, German and indigenous languages were not included in the search. Articles that did not specifically address tobacco issues in Namibia, articles published in non-Namibian newspapers and duplicate entries were excluded. The remaining 70 articles that met inclusion criteria were examined.
Articles were coded by JT according to their discussion of one or multiple themes that emerged from an initial examination of news coverage. Articles were coded as either favourable, neutral or unfavourable towards tobacco control. ‘Neutral’ articles offered only descriptive information, while ‘favourable’ articles were those that portrayed smoking as a problem in need of regulation, or that expressed frustration that tobacco control legislation does not yet exist. ‘Unfavourable’ articles were those that cast doubt on the need for regulation or on the harms of tobacco.
Results
The Tobacco Products Control Act
Prior to its independence from South Africa in 1990, Namibia had no tobacco control policy in place. South Africa governed South-West Africa as a province and imposed similar policies on the country. Since the South African Government had close ties with the tobacco industry, tobacco control was not on the agenda in either South Africa or South-West Africa.9 Once it became a sovereign nation, Namibia adopted a constitution enshrining a public health mandate for government. Article 95 of the Constitution obliges the national government to actively promote the welfare of its people through the enactment of public health policies. Article 95 has been used to justify the prioritisation of public health over economic interests, and to support tobacco control action within the Ministry of Health.10 According to Bashupi Maloboka, Head of Health Programmes and lead focal person for tobacco control at the Ministry of Health, the ministry began contemplating tobacco control legislation in 1991, shortly after independence.11
Nearly two decades later, the Tobacco Products Control Act of 2010 would invoke the nation's public health mandate in its preamble, recognising that tobacco use ‘severely affects the health of individuals contrary to the provisions of the Namibian Constitution.’ The Act was mainly modelled after legislation in South Africa. However, ratification of the FCTC in 2005 gave the Ministry of Health an opportunity to re-examine the existing tobacco control bill and align its provisions with those of the FCTC.11 As a result, the bill was revised to include provisions addressing passive smoking, illicit trade and youth smoking. The principal tobacco control persons at the Ministry of Health have firmly stated that the adoption of the Tobacco Products Control Act would not have occurred, or the provisions of the Act might have been severely weakened, without FCTC ratification.11 ,12 Once the bill was introduced in Parliament, it was supported by Members of Parliament across party lines.10 ,12 On 19 March 2010, the Tobacco Products Control Act was signed into law by the President and was promulgated on 14 April 2010. Table 1 compares the most important provisions of the FCTC against the content of the Act. The Act also mandates the formation of a Tobacco Products Control Committee to oversee its enactment and propose future amendments.
Comparison of select provisions of the FCTC and the Tobacco Products Control Act.13–15
Media coverage of tobacco control legislation
Namibia with its small and thinly distributed population, has only two daily English language newspapers, The Namibian (also published in Oshiwambo) and the government-owned The New Era (published in several indigenous languages and distributed to rural areas). These two newspapers represent the most widely circulated publications in the country, and featured 68 out of the 70 total articles identified. The remaining two were featured in the Namibia Economist, a weekly publication.
All articles evaluated were either favourable or neutral towards tobacco control. None were dismissive or broadly against tobacco control policy and/or in favour of the tobacco industry. Approximately half the news articles identified focused on the Tobacco Products Control Act (36 of 70). Of these, 21 (30%) highlighted delays surrounding tobacco control legislation, 8 (11%) stated that the Act was ‘arriving’, and 13 (19%) raised questions about the Act's implementation. Thirteen (19%) of all articles made direct reference to Namibia's obligations to the FCTC. Twelve (16%) articles covered cigarette smuggling issues. Tobacco industry attempts to interfere with legislation were mentioned in 6 (9%) of all articles.
According to one of the key tobacco control advocates in the Ministry of Health, journalists served as ‘watchdogs’ for legislative progress:
You know what the media did, what I liked about it, is the media phoned the Minister—contacted the Ministry [of Health]—‘How far is the Act? How far [are] the regulations? The Act was passed and we are celebrating World No Tobacco Day every year.’ What I liked is that they kept the Minister on his toes to ensure that this Tobacco Act is passed. They also spoke [out about] their unhappiness [that] the regulations had not been passed yet.12
The Cancer Association of Namibia (CAN), the only civil society organisation supporting tobacco control advocacy efforts, specifically engaged with news media to follow-up with government on the legislation.18
World No Tobacco Day (WNTD) events were regularly featured, accounting for 17% of all tobacco-related news articles. It was on WNTD in 1998 when the Minister of Health, Dr Libertine Amathila, first announced the government's intention to develop the Tobacco Products Control Bill. The Minister assured the public that the law would ‘gradually make sure that all restaurants had non-smoking areas because, as things stood, the rights of non-smokers were not recognised.’19 The Namibian headline: ‘Amathila to take on tobacco industry’ marked the beginning of coverage of the proposed legislation. In subsequent years, WNTD continued to spark media and public interest in tobacco as a health problem for Namibians, and prompted questions about the status of the proposed legislation. Headlines occasionally aligned with WNTD themes: ‘Poor hit worst by tobacco’20 (WNTD theme ‘Tobacco and poverty—a vicious cycle’, 2004), ‘Women now target of tobacco industry’21 (WNTD theme ‘Gender and tobacco’, 2010). WNTD also provided government officials the opportunity to explain legislative delays. During a WNTD event in 2011, the Minister cited industry interference as a barrier to implementation:
This is not an easy law to implement because of the multibillion-dollar tobacco industry. It is not easy to say no to money, but we are and remain determined to implement this act.22
Tobacco industry interference and legal intimidation
It is unclear what influence tobacco industry presence had on early drafts of the bill. No cigarettes are produced in Namibia, and all cigarettes are imported, mainly from South Africa where British American Tobacco (BAT) remains the dominant industry player for the region. In early 2000, the Ministry of Health and Social Services invited representatives from the tobacco industry to participate in the formulation of tobacco control legislation alongside the Cancer Association of Namibia (CAN) and Ministries of Trade, Finance, Justice and Agriculture.10 Industry representatives were again invited to consultations in 2005.
In a known instance of tobacco industry interference, BAT falsely informed the Ministry of Health that Namibia could not ratify the FCTC prior to passage of national tobacco control legislation.23 Namibia participated in negotiations leading to the FCTC, and signed the treaty in January 2004, but was slow in ratifying the FCTC subsequently. The lack of legal expertise within the Ministry at the time meant that the misleading opinion went unchallenged. Even The Namibian reported that ratification could not take place prior to enacting tobacco legislation.24 At a meeting in May 2005, the legal advisor to the South African Minister of Health heard about this mistaken belief and informed the Namibian Minister of Health that FCTC-compliant legislation was not a precondition for ratification.23 Once the Minister was made aware of this, the Convention was ratified by the Namibian Parliament in November 2005 and entered into force in February 2006.
While limited information on industry interference could be obtained from interviews, news coverage suggests a more intense campaign from the tobacco industry since passage of the Act in 2010. Nearly all media coverage of industry opposition occurred in 2011 and 2012. The tobacco industry used recent litigation against cigarette plain packaging legislation in Australia to intimidate Namibian officials. The New Era described BAT as ‘fighting the Act with serious threats to take the government to court if it dared to implement the Act. BAT has been citing the Australian court case as an example of how far it is prepared to go to fight the Namibian government…’25 These legal threats were accompanied by claims that provisions of Namibia's Tobacco Products Control Act violate the company's ‘Rights to Property’ and ‘Rights to Freedom of Expression’ conferred by the Namibian constitution.26
Delays, public confusion and lack of government capacity
Since the first public announcement in 1998, newspaper articles regularly informed the public that tobacco control legislation was forthcoming.27–31 However, insufficient staff capacity, competing priorities and administrative delays stalled progress in the ensuing years.10 ,32 ,33 In 2005, the tobacco bill was drafted with further input from the Ministries of Health, Trade, Agriculture and Finance and BAT; the draft appeared to be in its final stages when it was sent to the office of the Minister of Health, and subsequently to the Ministry of Justice, for legal consultation. However, no visible progress on the legislation took place and the media began to lose faith in the ability of the Ministry of Health to pass the legislation. By 2009, The Namibian described the situation as follows:
What's happened to Namibia's proposed law to ban smoking in public places? Well, according to the Ministry of Health… the Tobacco Control Bill is with the Ministry of Justice…. Not so says the Ministry of Justice, it's with the Ministry of Health. Sixteen years and counting and still the proposed law seems to be just so much smoke…languishing somewhere in a void between ministries.34
The slow pace of progress was a common theme for reporters. Of the 21 news articles discussing the legislation prior to 2010, 11 articles specifically drew attention to delays to enactment. This was due in large part to the lack of capacity within the Ministry of Health:
We didn't have legal experience ourselves [in] the Ministry…The other thing is that there was not a focal person per se just concentrating 100% on the tobacco control activities.33
With no legal expertise in the Ministry of Health, concerted activity on the bill did not take place until a legal drafter was hired in 2009 to finalise the document.10
Despite eventual passage of the Act in 2010, doubts about the government's ability to draft the regulations needed for implementation were also raised by the media. Newspapers discussed public confusion around when the law would go into force.35 ,36 Restaurant owners reported their frustration at not knowing when they must ban smoking in their establishments.37 Dr Kamwi, the Minister of Health, also expressed his embarrassment over the implementation delays to The Namibian:
The tobacco control act, a law the Minister has supported passionately, is ‘not yet functional because the regulations are not yet in place’…The Minister demanded that the relevant persons assigned to complete the draft regulations do so urgently. ‘It is becoming a shame on us that we are unable to control this bad habit whilst having the law at our disposal.’38
Failure to finalise the regulations in a timely fashion has been attributed to low staff capacity and legal concerns with BAT,25 ,26 ,39 but also to the low response rate from nominated individuals required to establish the Tobacco Products Control Committee.36
Challenges and opportunities for implementation
Though some provisions address youth tobacco use, the Act does not prohibit the sale of single or ‘loose’ cigarettes, which is the primary means through which Namibian youth access cigarettes in townships.40 The original draft of the tobacco bill prohibited the sale of loose cigarettes, but this section was eliminated.10 Members of Parliament expressed concerns that this would be detrimental to the rural poor who rely on single stick sales as a source of income.17 ,41
In this respect, Namibia's experience is similar to South Africa's experience. The sale of loose cigarettes was banned in the 1999 Tobacco Products Control Amendment Act, but subsequent, amendments removed the ban. It was argued that many informal retailers were dependent on loose cigarettes sales.42
In preparation for the smoke-free law, inspectors were trained to ensure public and owner compliance.12 ,43 Thus far, they have not been called upon to conduct inspections. Based on anecdotal evidence, Namibians continue to smoke indoors.37 ,44 Representatives from the Cancer Association of Namibia report that non-smokers regularly contact the CAN to complain about the delayed implementation of the smoking ban.18 (CAN ceased direct involvement with the legislation in 2006 after consultations on the bill concluded.45)
Namibia is in a peculiar position with respect to excise taxes. Section 36 of the legislation allows the Minister of Health to raise revenues by imposing a levy on the import, distribution or sale of tobacco products. As a member of the Southern African Customs Union (consisting of South Africa, Namibia, Botswana, Lesotho and Swaziland), the excise tax is set centrally, but de facto by South Africa, given the country's dominance in the region. South Africa has followed an effective tobacco control strategy since 1994,9 centred largely on rapid increases in the excise tax (increased by 168% from 1994 to 2000 in real, inflation-adjusted terms, and by 103% from 2000 to 2012). Southern African Customs Union (SACU)-wide revenue from the tobacco excise tax goes into the Common Revenue Pool, and is subdivided between member countries.46 However, if the additional tax is called a levy, as is proposed in the legislation, the revenues would accrue directly to the country.47
Should Namibia follow this route, it would more carefully have to monitor the quantity of tobacco products entering the country.48 Official trade statistics on Namibia's consumption are not believable,49 so a positive spin-off from imposing a levy on cigarettes could be improved data on tobacco consumption.
The Ministry of Health is experiencing substantial pressure for immediate implementation of the law.17 ,41 While regulations were drafted and released for public comment in late 2011,16 they have yet to be finalised. The Minister continues to receive numerous calls and letters from media outlets, the hospitality sector and the public, demanding updates on when the Act will be implemented. By May 2012, only nine of 13 members of the Tobacco Products Control Committee had been appointed. The opinion of civil society organisations is that the public has growing doubts about the government's ability to implement and enforce the Act.18 ,40 ,50 In the absence of visible government action, public support for tobacco control legislation may weaken over time.
The two most immediate obstacles to the implementation of the Act are insufficient staff capacity to drive progress and the lack of legal expertise to support drafting of regulations. For the individuals involved in tobacco control within the Ministry of Health, implementing the Act is not a primary duty.33 The recent retirement of the Ministry's primary tobacco control lead person may also present some setbacks.17 Without a focal person whose sole duty is to put tobacco policy into practice, there is inadequate capacity to ensure swift enactment of the Act's provisions. At the time of writing (January 2013), no person employed within the Ministry of Health is equipped with the legal background and skills to assist in the drafting of the Act's regulations.10 ,33
Discussion
The authors recognise several limitations to this study. Interviewees were comprised of those accessible to the investigator who were willing to be interviewed. Members of Parliament who were involved in the Act could not be reached. There was great variability across interviews in terms of the respondents’ expertise and ability to speak to past events. Some interviewees lacked sufficient knowledge of tobacco issues outside the realm of tax regulation and illicit trade and were unable to comment on the process of passing legislation. The authors attempted to validate information across sources where possible; however, information could not always be independently confirmed due to a lack of paper trail, and the fact that only a very small number of individuals in the country work on tobacco issues. Because interviewees spoke in their professional capacity, it is also possible that respondents had self-serving or protective motives. Still, themes familiar to African tobacco control efforts emerged from these interviews and from our analysis of national news coverage.
Ratification of the FCTC can drive tobacco control progress in low-income and middle-income nations by strengthening legislation and supporting the authority of governments pursuing tobacco control policy. Ratification of the treaty gave Namibia the opportunity to revise its tobacco control bill to include more stringent provisions in line with WHO FCTC standards. It also provided the Ministry of Health with an international mandate justifying action against tobacco.
The media can serve an important role in promoting tobacco control legislation. They can support legislative progress by functioning as government ‘watchdogs’, highlight tobacco use as a problem in need of regulation, and portray tobacco control in a positive light. Health advocates and journalists in resource-constrained nations should use media to pressure governments to forward tobacco control legislation.
Finally, staff and legal capacity within health ministries is vital to the speedy enactment and implementation of tobacco control legislation in resource-constrained nations. Namibia's Ministry of Health lacked sufficient legal expertise to avoid being misled by the tobacco industry. Namibia's tobacco control bill also lay dormant for years awaiting legal drafting even after final consultation with stakeholders in 2005. Until there is sufficient legal capacity within the Ministry of Health, Namibia will need to rely on outside support in order to resist intimidation from the tobacco industry.
Namibia's government has an opportunity to reduce smoking by imposing additional tobacco levies above the tax rates set by SACU. The Act specifically refers to the imposition of tobacco levies. The South African Treasury has confirmed that SACU member countries are able to impose additional country-specific levies on goods such as tobacco and alcohol.51 The fact that Botswana has imposed a 30% levy on alcohol above the SACU tax rate, and is contemplating imposing a levy on cigarettes is an important precedent for Namibia.52 ,53
This case study offers a narrative of tobacco control for a country that experiences many of the typical constraints of a small, developing nation. It is encouraging that a sparsely populated middle-income country with a host of competing public health pressures was able to pass legislation that largely conforms to FCTC standards. The Namibian example is also frustrating because the process took so long, and even now (January 2013) the legislation has not been implemented because the regulations have not been promulgated. With the Tobacco Products Control Act adopted into national legislation after nearly two decades of effort, the prospects for reduced smoking in Namibia are favourable for the future but only if the government acts to implement and enforce its legislation. How quickly Namibia will be able to find sufficient resources and the political will to meet these challenges remains to be seen. This, indeed, is the quandary faced by many low-income and middle-income countries.
What this paper adds
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This case study illustrates the challenges of pursuing tobacco control legislation in a small, developing country in Africa.
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The factors that have contributed to tobacco control outcomes in Namibia are examined through personal interviews and analysis of news media.
Acknowledgments
This study would not have been possible without Verona Du Preez, whose incredible support and assistance with reaching contacts in Windhoek, Namibia were essential to the project. We thank Jeffrey Drope and Holly Jarman for their input on early drafts of this paper. We are also grateful to our anonymous reviewers for their helpful insights throughout the revision process.
Footnotes
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Contributors JT directed the study, conducted interviews, examined news articles, wrote the first draft and revised subsequent drafts. CvW reviewed and revised drafts and guided several key components of the paper.
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Funding We are grateful to the University of Michigan School of Public Health and the American Cancer Society (Grant 10497) for providing funding support for this project.
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Competing interests None.
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Ethics approval Health Sciences and Behavioural Sciences Institutional Review Boards (IRB-HSBS).
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Provenance and peer review Not commissioned; externally peer reviewed.