Using legal capacity building to achieve Sustainable Development Goal 3.4: a global case study

Abstract

The McCabe Centre for Law and Cancer’s international legal training programme (ILTP) aims to raise the capacity of government lawyers from low- and middle-income countries to use the law to address noncommunicable diseases (NCDs). We used qualitative data to evaluate impacts of this long-term capacity-building programme to complement tangible impacts, such as law and policy reform found in an earlier evaluation. We undertook 17 interviews with alumni of and stakeholders involved with the ILTP over the period 2014–23. The interviewer conducted semistructured interviews. Two reviewers used inductive content analysis to code the interviews. We found that alumni and stakeholders valued the programme’s role in building networks of participants with legal skills relevant to NCDs and in empowering individuals to become champions for NCDs. Interviewees also took a broader view of impact than the completion of individual law and policy reform projects, considering many law and policy changes, regional initiatives, and leadership roles of alumni beyond those formally supported as part of the programme to have been a key impact of the programme. The study highlights the need to invest in NCD legal capacity building and leadership for the long term. We find that building a community of people with the skills, confidence, and commitment to act on NCDs is a key impact of such programmes, in addition to laws and policies developed.

Contribution to Health Promotion.

• Law is a cost-effective and powerful tool to address noncommunicable diseases (NCDs). Yet laws addressing major NCD risk factors are underutilized.

• We examined how building legal capacity contributes to the prevention and control of NCDs in low- and middle-income countries.

• The study explores the outputs of a long-term legal training programme beyond law reform, which include the building of networks and NCD champions.

• These findings highlight the need to invest in NCD capacity and leadership for the long term and include important implications for those hoping to do so.

The world is not currently on track to meet Sustainable Development Goal (SDG) target 3.4 of a one-third reduction in premature mortality from noncommunicable diseases (NCDs) by 2030. In a period when global health funding is increasingly limited, and support from multilateral institutions may be reducing, one powerful, cost-effective, and underutilized tool to address NCDs is the law.

This article explores how capacity building can support better use of laws to address NCDs, through qualitative interviews of alumni and stakeholders of the McCabe Centre for Law and Cancer (McCabe Centre)’s international legal training programme (ILTP). The ILTP aims to raise the legal capacity of government lawyers in low- and middle-income countries to address NCDs and help achieve SDG target 3.4.

A previous evaluation found that the ILTP contributed to law and policy reforms in 30 countries with tobacco control laws or regulations by far the most common measure worked on, the defence of laws from legal challenges in five countries, and the initiation of health care cost recovery litigation in one country, through structured ‘priority projects’ supporting participants to undertake legal work of priority to their country or organization (Slattery et al. 2025). This evaluation builds on this prior evaluation to give a fuller picture of the relationship between capacity-building efforts and law and policy outcomes in NCDs. It does so through data collected from 17 qualitative interviews with former participants of the ILTP (alumni) and those working closely with the programme over the first decade (stakeholders). The study identifies important implications for those working in global health programmes and/or capacity-building or training initiatives, including on the nonlinearity of law and policy change, the importance of relationship building, and the role of personal and professional impact in developing champions.

Method

We interviewed 17 individuals (12 alumni and six stakeholders, including one participant who fell into both categories). To arrange alumni interviews, the McCabe Centre sent an expression of interest to an email list containing all ILTP alumni. This included more than 200 alumni; however, this did not include participants who started but did not complete the ILTP, participants who did not have current contact details with the McCabe Centre, or participants who had opted out of receiving email communications. Eight participants responded to this expression of interest. To ensure an adequate number of alumni interviewees and a diverse representation of gender, countries/regions, and ILTP cohorts, the McCabe Centre sent follow-up emails to 13 alumni who had been in recent contact with the McCabe Centre and who matched underrepresented characteristics for the alumni interviewees, which resulted in a further four interviews. All alumni who responded to the expression of interest were offered an interview.

To arrange stakeholder interviews, the McCabe Centre sent emails requesting interviews to a list of 13 stakeholders who had been involved in the ILTP between 2014 and 2023, of whom six responded. This included stakeholders at relevant World Health Organization regional offices as well as stakeholders from the WHO Framework Convention on Tobacco Control (WHO FCTC) Secretariat, the Pacific Community (SPC), and the Australian Government. For some stakeholders, contacts involved in the ILTP were no longer in the relevant role, which likely explained why no response was received.

Semistructured interviews were conducted in English and online between August and December 2024. The first author undertook all interviews. For some interviews, the author was accompanied by McCabe Centre’s regional managers/advisors, who are lawyers based within the region of training participants who serve as a first point of contact for support.

Interview transcripts were reviewed for accuracy by the first author and analysed by the first and second author. Transcripts were coded through inductive content analysis (Vears and Gillam 2022). Ethics approval for the study was provided by the Cancer Council Victoria Human Research Ethics Committee.

Participants

The previous evaluation found that from 2014 to 2023, the ILTP had 450 participants from 97 countries and territories over its 13 deliveries (including nine in-person and four online). The majority of these alumni came from WHO’s Western Pacific (36%), African (24%), Southeast Asian (21%), and American (11%) regions, with few coming from the WHO European (3%) and Eastern Mediterranean (5%) regions (Slattery et al. 2025). Slightly more women (53%) than men (47%) participated in the ILTP. The overwhelming majority of alumni came from government (79%), with smaller proportions coming from nongovernment (e.g. civil society and academia) (14%) or intergovernmental organizations (7%) (e.g. WHO regional offices) (Slattery et al. 2025).

The 12 alumni interviewees represented 3% of the McCabe Centre alumni. Alumni interviewees were generally representative of the total alumni pool, with interviewees coming from 10 different countries and the four most commonly trained WHO regions (Southeast Asia, Western Pacific, Africa, and Americas) and included participants from eight of the 13 ILTP cohorts, including six in-person and two online. The gender balance of alumni interviewees was even, in line with the generally even split in the total pool. In line with the total pool, the majority of interviewees came from government (eight), while the remainder came from nongovernment organizations (e.g. civil society and academia) (three) and intergovernmental organizations (one).

Stakeholders were principally from organizations that nominated or funded participants for the ILTP (such as the World Health Organization or regional organizations) and included one male and five females. For a table of all interviewee characteristics, see Supplementary File 2.

Ethical approval

Ethical approval for this research was provided by Cancer Council Victoria Human Research Ethics Committee (HREC 2404).

Results

Interview transcripts were coded based on the following five categories:

1. Building confidence in using law for NCDs

2. Mobilizing law and NCD networks and working together

3. Priority projects: opportunities and challenges

4. Mode of delivery: in-person compared to online

5. Broader impacts of the McCabe Centre and/or the ILTP

Categories were developed by the first author and were further refined with input from all authors. For examples of the responses that fell within each category see Supplementary File 1.

Table 1 outlines the number of times each category was identified by the two reviewers across all interviews and divided between alumni and stakeholder interviewees.

Table 1.

Number of times each category identified per interview and averaged across all interviews (n = 17), alumni interviews (n = 12) and stakeholder interviews (n = 6).

Number of times each category identified by the two reviewers across ‘all’ 17 interviews and averaged
Category short name	Reviewer 1	Reviewer 2	Average number of times identified	Average number of times identified by interview
Building confidence	94	74	84	5
Networks	116	103	110	6
Priority projects	64	39	52	3
Mode of delivery	51	48	50	3
Broader impacts	34	44	39	2
Number of times each category identified by the two reviewers across 12 ‘alumni’ interviews and averaged
Building confidence	72	52	62	5
Networks	81	76	79	7
Priority projects	53	39	46	4
Mode of delivery	39	33	36	3
Broader impacts	23	35	29	2
Number of times each category identified by the two reviewers across six ‘stakeholder’ interviews and averaged
Building confidence	27	30	29	5
Networks	38	33	36	6
Priority projects	16	4	10	2
Mode of delivery	14	18	16	3
Broader impacts	14	16	15	3

Coding discrepancies between the reviewers largely relate to priority projects and are accounted for by reviewer one’s pre-existing familiarity with the topic of participants’ projects. Potential bias may have also existed given Reviewer 1 conducted the interviews and has been involved in the delivery of the ILTP since 2017.

Discussion

From the five categories identified, three important outcomes were observed. These three outcomes include that the ILTP contributed to (i) the creation of networks for law and NCDs, (ii) empowered NCD champions, and (iii) intangible impacts.

Outcome 1: building networks that facilitate law and noncommunicable disease action

The results show that the building of networks of lawyers with expertise in NCDs was the most valued output of the ILTP. Alumni and stakeholders discussed this category more than any other category. Networks included both international and regional networks, with three alumni and one stakeholder specifically crediting the programme with creating strong regional NCD networks in the Caribbean, South America, and Africa:

The sharing of knowledge and experience from the different countries participating in the meeting … that was a very rich one… And that fusion of knowledge was really, really important. And I think it was one of my best experiences hearing beyond the African Region to what is happening. (African stakeholder)

Interviews considered stakeholder involvement in identifying participants to be critical to building networks. Five interviews (three stakeholder and two alumni) noted that stakeholders were better placed to work with countries to identify participants who could benefit from the training and contribute to an expanding NCD network on an ongoing basis. Four alumni interviews highlighted how participants moving away from NCDs through changes or departures from roles were a common challenge experienced in completing priority projects:

I remember the first year we were a bit hands off in terms of who was nominated… And I realised that after the people were trained, I recall there was one person who ended up migrating. So … the knowledge and skills that were developed were just lost… One lesson we learned from that was to really be hands on, engage with who was being nominated. (Pacific stakeholder)

Of course, the challenge was that you would not know whether down the road a year later or two, there may be a turnover that might move to another department. (African stakeholder)

In-person training was seen as better for facilitating networking. Of the nine interviewees who expressed a preference for in-person over online training, five cited networking as the reason for this preference. Two interviewees (one alumnus and one stakeholder) noted the importance of discussions over lunch and coffee breaks in building relationships and networks:

[ILTP was a good experience] particularly the physical ones, because there was kind of more interactions, you could have a bilateral one-on-one discussion over lunch or after a meeting and so on. (African stakeholder)

However, many interviewees who expressed a preference for in-person training still recognized the benefits, including the networking benefits, of online training. Alumni of the online course valued networking opportunities provided and suggested ways of strengthening this element. For example, one alumnus suggested using a messaging platform, such as WhatsApp, and including an in-person component:

Online just makes your life, it just makes it way simpler. Things become possible that wouldn’t normally be possible because you can coordinate. (Caribbean alumna)

Covid actually opened a lot of doors through the virtual modality… With Covid we managed to bring [McCabe] to the [Eastern Mediterranean] Region. (Eastern Mediterranean stakeholder)

Outcome 2: empowering individuals to become noncommunicable disease champions

The second most valued outcome identified in interviews—raised on average five times in every interview—was the importance of the ILTP in building confidence in using law to address NCDs and creating champions for NCDs. Three alumni considered the ILTP to be a pivotal point in their professional careers or personal lives, and three spoke about how the ILTP encouraged them to do further related study. Six interviewees noted the value to other NCD bodies or organizations given how alumni went on to work with or be involved in key NCD bodies, such as the WHO FCTC Secretariat, Knowledge Hubs, and important COP positions:

[The ILTP was] one of my first contacts with … the world of the FCTC and the tobacco world. So I was really new to the field. I have been working with … the FCTC and tobacco from that day. So it shaped my career in that manner. So it really made a huge impact’… ‘[A]t some point [the ILTP] changed my life… And so I am always thankful for what [McCabe does]. (South American alumnus)

Five stakeholders raised how they rely on ILTP alumni for NCD activities or that working with ILTP alumni on NCD measures is easier than working with those who had not been trained. Five stakeholders saw the McCabe Centre programme filling a gap that other NCD stakeholders did not have the resources to fill. One Pacific Stakeholder noted that they were ‘eternally grateful to McCabe for this’:

Working on NCD related laws with [McCabe ILTP alumni] is easier than working with someone who has been thrown into the deep end and hasn’t been exposed to programs like this. (Pacific stakeholder)

Outcome 3: creating impact beyond nominated priority projects (intangible impacts)

The results show that individual priority projects, despite being a major impact identified in the previous quantitative evaluation, were not considered by interviewees to be the major impact of the training, and that interviewees took a broader view of impact, including contribution to regional initiatives or laws and policies outside of priority projects. For stakeholders, priority projects were the category that interviewees were least likely to raise, and for alumni interviewees, this was the third likely category to be raised (see Table 1). We have called impacts beyond priority projects intangible impacts, as these impacts are harder to measure or quantify.

Alumni spoke of many factors outside of their control affecting priority projects. These included changing political priorities and electoral cycles and personal or professional impacts (such as changing work priorities). For example, two alumni reported returning home after ILTP only to find that priority projects were now politically unfeasible or challenging:

The Minister at the time, who was […] very strong in terms of tobacco control, he was changed …Where we are now in 2024 is that we now have another Minister who we can say, yes, it’s quite active in this space…. but it took some time to get here. It took some time also for him to get here… So that is why we did not see the implementation of that particular priority project. (Caribbean alumna)

Stakeholders preferred to talk about impacts beyond individual priority projects. Stakeholder interviews referenced broader impacts on average three times per interview compared to individual priority projects, which were referred to on average just twice per interview. Two stakeholders spoke about how entire regions were benefited from a ripple effect once countries in the region introduced new NCD laws. Three stakeholders spoke about influences of the McCabe Centre’s work beyond the ILTP, e.g. through technical assistance outside of the ILTP or through engagement in key regional NCD instruments, such as the Pacific Legislative Framework on NCDs―a regional framework for legislative reforms addressing key NCD risk factors adopted in 2021. One stakeholder specifically raised how law reform was a challenging output of a capacity-building programme given it is very difficult to ask one person to influence a whole country:

I think the program has had an impact… I mean, we have got obviously the cases in Kenya… An [alumnus] was one of the critical council’s defending that case. And the outcomes have been very positive today for tobacco control, not just in Kenya but in the region and we have this raft of legislation adopted, particularly for tobacco control, in a number of countries. (African stakeholder)

[Technical assistance from the McCabe Centre has] played a key role in two successes in the region. One is the plain packaging in Saudi Arabia and the second is plain packaging in Oman. So we are really very happy with this collaboration, and we think it is one of the best collaborations. (Eastern Mediterranean stakeholder)

Interviewee responses frequently emphasized the role of McCabe Centre’s regional managers/advisors in relation to the ILTP’s broader impacts. Seven interviewees (three stakeholders and five alumni) noted the crucial role regional managers/advisors played, which included providing support and technical assistance to alumni and presenting at events organized by alumni. Three interviewees linked this role to other broader impacts given the role was based in region and managers often attended key regional meetings and events and provided input into regional instruments:

[The McCabe Centre Regional Manager for Africa] is a walking encyclopaedia in our region and you know I would like to thank her. Anytime you knock on her door, she’s willing to talk to you. And for me that is very important. (African alumnus)

Alumni comments also identified the impact of the programme on their personal and professional lives:

I will always be an ambassador for McCabe because I know the impact and that it is like a gift that keeps on giving. (Caribbean alumna)

Implications

Our earlier study found that the ILTP contributed to the adoption of laws and policies in more than 30 countries—covering a population of nearly 3 billion people. Many of these laws and regulations focused on tobacco control ranging from comprehensive measures to laws and regulations implementing specific measures, such as plain packaging or graphic health warnings. However, the earlier study also found that the adoption of NCD laws and policies was incomplete or ongoing in at least 13 other countries, with well-known obstacles, including political will, competing priorities, and industry opposition often impacting priority projects (Slattery et al. 2025).

Qualitative interviews demonstrate that the ILTP’s impacts were not only in the adoption of laws and policies in more than 30 countries but also the development of champions for NCD prevention and control and the development of laws and NCD networks across countries that were able to serve as a resource for other initiatives on NCDs. In this way, qualitative interviews also capture the achievements of alumni who continue work on priority projects, in some cases more than a decade after attending the ILTP, and face significant challenges.

The study provides implications for those working in, funding, and evaluating capacity-building programmes. These include that despite the difficulty of identifying broader impacts, these impacts are seen as some of the most important outcomes of long-term capacity-building work. The study shows that stakeholders see the value of these broader outcomes and that these can in turn result in law and policy change. One Pacific Stakeholder described ‘a wave of legislative amendments’ after the ILTP began, beyond the formal priority project of the participant. The broader impacts identified in interviews require working closely with stakeholders to identify potential champions, thinking through how to maximize networking opportunities in different formats and detailed qualitative evaluation, all of which are resource intensive. However, our interviews show that these less tangible outcomes often provide the foundations for ongoing collaboration beyond the timeframes of a specific programme and should not be undervalued. The study also complements other work exploring the importance of evaluating intangible impacts of capacity building despite more easily quantifiable outcomes often being preferred by funders (Vallejo and Wehn 2016).

Conclusion

The world is not on track to reduce premature deaths from NCDs by one-third and meet SDG target 3.4 (World Health Organization 2025). The WHO has recognized law as a key tool to address NCDs and achieve target SDG 3.4 (World Health Organization 2024). As multilateral institutions, including WHO, are facing reducing budgets and headcount, the importance of having officials within countries with the legal skills to progress NCD initiatives adapted to local environments is crucial. This study highlights the need to invest in NCD capacity and leadership for the long term—both to achieve specific laws and policies and to build a community of people with the skills, confidence, and commitment to act on NCDs.

Author contributions

Clare Slattery (Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Validation, Writing—original draft, Writing—review & editing), Abbey Malone (Formal analysis, Methodology, Validation, Writing—original draft, Writing—review & editing), Suzanne Zhou (Conceptualization, Methodology, Supervision, Writing—review & editing), and Hayley Jones (Conceptualization, Writing—review & editing)

Supplementary material

Supplementary material is available at Health Promotion International online.

Conflicts of interest

C.S., S.Z., and H.J. were involved in the delivery of the ILTP.

Funding

Direct costs for the ILTP were principally provided by the Australian Government. Some participants were funded by other sources, including the Union for International Cancer Control, the WHO, the FCTC2030 Initiative, the American Cancer Society, the William Rudder Trust, and the Norwegian Government. A small number of participants, particularly from high-income countries, were funded by their home governments or institutions. Funding for the work of one author on this study was provided by the Australian Research Council (ARC LP210100204). Cancer Council Victoria has funded all other underlying staff costs for this study and the ILTP.

Data availability

Deidentified data is available on reasonable request through the McCabe Centre for Law and Cancer.