Multi-sectoral implementation interface framework (MIIF) to achieve the objective of tobacco-free Himachal Pradesh

Abstract

The limitations observed in achieving the goal of a tobacco-free Himachal Pradesh have necessitated the need to contextualize the existing policy directives in tobacco reduction. Our observation has been that despite having clearly defined policy guidelines and laws, the implementation may not have followed suit. An analysis of the gaps observed had led us to develop an implementation interface framework involving stakeholders from multiple sectors.

Background

Himachal Pradesh, a mountainous state in the northern part of India with a population of roughly 7 million people, became the first evidence-based smoke-free state among India’s main states in 2013, after Shimla, the capital city, was designated as such in 2010.[1,2] Simultaneously, the selling of smokeless tobacco, loose cigarettes, and bidis has been prohibited by the state. The most significant obstacles to delivering basic health care to the population are the state’s harsh geographical and climatic characteristics; however the state’s better performance on health indicators points to a willingness of the government to reach out to the remotest parts.[3]

Reducing tobacco use has been identified as the most effective strategy for achieving the global aim to promote the prevention of non-communicable illnesses, a major concern for healthcare providers.[4] Two nationwide surveys conducted throughout the country revealed a conflicting picture; while the Global Adult Tobacco Survey - 2 (2016–17) revealed a decline with 30.4% of men and 1.7% of women being tobacco users; the National Family Health Survey - 4 (2015–16) revealed an increase in tobacco use in the state (Himachal Pradesh).[5,6] Also, as per the NFHS-5 (2019–20), tobacco usage among men has decreased in most states, with the exception of Bihar, Himachal Pradesh, Goa, Gujarat, Mizoram, and Sikkim, where it has increased.[7]

As per available reports, one-third of men (33%) between the ages of 15 and 49 use tobacco in some form in Himachal Pradesh; cigarettes (20%), smoking bidis (18%), khaini (6%), and gutka or pan masala with tobacco (3%) are the most often used tobacco products by males. In urban regions, men use any form of tobacco at a somewhat greater rate than in rural areas.[8]

The State Government has established a State/District level coordination and monitoring committee to ensure that the programme on reducing tobacco use and laws governing its implementation are implemented effectively.[1]

In addition, an anti-tobacco campaign is underway in collaboration with the Health, Police, and Education Departments, as well as NGOs and PRIs, to ensure that tobacco products are not sold within 100 yards of educational institutions, with an effective ban in place.[1]

According to the Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply, and Distribution) Act, 2003 (COTPA) provisions, any police officer with the rank of sub-inspector or above, or any officer of the State Food or Drug Administration, or any other officer holding a rank equivalent to that of Sub-Inspector of Police, is authorized by the Central Government or the State Government to conduct surprise checks to see if the Act’s provisions are being followed.[9] These essential stakeholders such as the Department of Police, the Food and Drug Administration, the Department of Health, and the Department of Education are expected to guarantee that no one is seen smoking in public areas; that cigarettes and other tobacco products are not sold within 100 meters of educational institutions; and that tobacco products are not sold to or purchased by minors. They have the authority to seize tobacco advertisements, cigarettes, and other tobacco packagings that are in violation of the Act’s requirements, as well as tobacco products that are made or marketed without the required health warnings.[10]

Unfortunately, the existing guidelines, as an effective tool in the reduction of tobacco use among people, are experiencing limitations. As it is now nearly two decades since the WHO FCTC was formulated in response to the globalization of the tobacco epidemic, these seem to fall just short of what is required to tackle these challenges apparently due to a lack of implementation and enforcement of various sections of COTPA.[11,12,13] Though lack of enforcement is a worldwide trend that is worsening tobacco risks, progress on implementation and enforcement has been slow for a variety of reasons. Laws may lack clear norms or demands, or they may be inappropriately adapted to national and local settings. Furthermore, implementing ministries are frequently underfunded and politically weak in comparison to ministries responsible for economic or health development, as well as a lack of designated staff to look into tobacco control as a response of which, performance delays. Besides this, the role of stakeholders, most importantly primary care physicians, needs further understanding. Being in close contact with the population in general, the primary care physicians need to be an important element when planning for the implementation of the framework.

Observations leading up to the development of the framework

A joint initiative (Centre for advancing tobacco control in Himachal Pradesh: CATCH) of Dr. RPGMC Kangra at Tanda and The International Union Against Tuberculosis and Lung Disease (The Union) was established with the aim to facilitate the implementation of the World Health Organization Framework Convention on Tobacco Control (WHO FCTC/MPOWER) package in keeping with the commitment of the Government of Himachal Pradesh.[14]

Using an integrated multi-stakeholder approach, the initiative plans to use monitoring and evaluation and implementation research to strengthen capacity through training, workshops, and creation of resource material for creating subnational smoke-free environmental jurisdictions at the smallest civil administrative unit level of the state government, i.e., a development block by facilitating the implementation of FCTC recommendations. The initiative intends to identify solutions to the issues of the gaps in real-world situations through a holistic concept using multi-stakeholder engagement that incorporates effective monitoring and evaluation, capacity building, and implementation research approaches. Activities carried through the initiative have observed limitations in the implementation of tobacco control.

Need for a framework

As part of the defined activities of the Center for Advancing Tobacco Control in Himachal Pradesh, the following were the observations raising the need for a framework.

1. “No Smoking” signage is not displayed as per specifications of the law in a majority of public places, government offices, educational institutions, health care facilities, and random community settings, and more than three-fourths of study settings had no signage in their premises.

2. When signage is present, no contact details of the in-charge/authorized person were displayed on the signage.

3. The majority of the study settings do not have any specific tobacco control committee on their premises to look for the tobacco regarding violations.

4. Limitations in designating officials to look after the violations of COTPA; currently officials seem preoccupied due to the varying priorities, roles, and responsibilities.

5. Very few have attended district and state-level meetings regarding tobacco control.

6. No study settings have reported the visit of the enforcement squad for tobacco challans particularly.

7. The majority of the population as well as key stakeholders were not aware of Tobacco guidelines, WHO FCTC Article 5.3, quitline numbers, m-cessation services, etc.

8. There were no permanent tobacco vendor shops that were selling only tobacco and related products. None of the tobacco vendors carry licenses to sell tobacco and related products.

Addressing the need

The purpose of the MIIF is to provide a multi-sectoral implementation interface to achieve the objective of Tobacco-free Himachal Pradesh [Table 1]. The basic premise on which this framework is being proposed to be built is that coordination and collaboration at the block, district, and state level and within the jurisdictions acting at the interface of these geographies leads to improved outcomes, innovative responses, and better use of resources. The envisioned strategy coordinates the collaborative departmental response to tobacco use and related violations by providing a conceptual framework for identifying agreed-upon priorities. The framework reflects on some of the existing national policies, which appear complex in the process domains of knowledge and thus clearly need advocacy for a common understanding of public health policies, their scope, and the drafting process. After exploring the trends in tobacco prevention across our state, it is being clearly understood that a fundamental aim of each stakeholder is to prevent, reduce, and manage tobacco use and users. [Figures 1-2 and Table 2]

Table 1.

Multi-sectoral implementation interface framework (MIIF)

Interface Domains	Priority Actions	Monthly Meetings	Role Assignments	Evaluation process	Reporting Process
Gaps	1. Varying priorities of stakeholders 2. Lack of interdepartmental collaborations 3. Inadequate availability of enforcement squad 4. Minimal involvement of the community.	1. Infrequent conduct of monthly, quarterly, and annual meetings related to tobacco control 2. Infrequent conduct of interdepartmental meetings 3. Lack of Training. 4. Lack of relevant awareness of tobacco-related violations.	1. Lack of designated staff in departments to check for tobacco-related violations. 2. Staff overburdened with other assigned works.	1. No sustainable and evaluable processes in place 2. Lack of regular enforcement	1. Infrequent and irregular monthly, annual reporting to the Tobacco control cell.
Approaches	1. Facilitation of implementation as identified in the interphase. 2. Strengthening of partnership with key stakeholders. 3. Capacity building	1. Creating avenues for notification and smooth conduction of meetings and training with support from concerned state and district officials,	1. Leaders, as part of the interphase, will identify and specify assignments and define terms of reference.	The setting of timelines for a) monitoring and b) evaluating the monitored parameters.	Regular reporting from every department by using an online tool or shared platform
Activities	1. Establishing inter-departmental working groups involving health, police, excise, and food & drug safety departments. 2. Establishing terms of reference for coordination	1. Coordinating district level training programmes for all departments 2. Identifying the gaps and challenges during the implementation of the framework and addressing them during the monthly/quarterly meetings.	1. Establish criteria for enforcement success and failure and preparation and sharing of the same, for example, the number and quality of enforcement in a month.	Strengthening enforcement through routine and non-routine checks.	Provision of technical support and strategic guidance through leadership initiatives
Outcomes	1. Establishment of Institutional framework 2. Establishment of Enforcement squad 3. Capacity Building 4. Dynamic Challan system	Introducing dynamics in the enforcement system through the highlight of bottlenecks	1. Identify or create a Budget Head for depositing Challans and penalties collected for Tobacco Control violations. 2. Utilization of the budget head for tobacco control activities.	Monthly and Quarterly reports from the field on level of enforcement and compliance	Tobacco-free Declaration of spaces.
Indicators	1. Establishment of DTCC, DLCC, BLCC, TCC in District Kangra 2. Identification of enforcement squad per block/district 3. Movement of Enforcement squad 4. Number of district-level trainings/workshops 5. Number of challans issued per block/district 6. Amount/Fine collected for tobacco-related violations	Number of officials trained during meetings/workshops. Number and nature of meetings conducted	Identification of leaders from each stakeholder department.	1. Evolution of monthly and quarterly reports from the field on level of enforcement and compliance and fines collected through various Section provisions of COTPA	1. Number of blocks declared tobacco-free

Figure 1.

Structure of Multi-sectoral Implementation Interface Framework

Table 2.

Priority actions and Lead under the interface framework

Priority actions	Health	Police	Food Safety	Excise
Capacity building	Lead
Transparent reporting of challans and fines		Lead
Checking Tobacco Vendor License and Registration certificates.			Lead
Check on the illicit trade of tobacco products/tax evasion				Lead
Develop new and innovative responses	Lead
Monitoring performance and evaluation	Lead

Figure 2.

The flow chart of the framework

The guidelines, as mentioned in NTCP for DTCC, appear more theoretical and non-dynamic in nature. To identify bottlenecks, these lack the inherent capacity for dynamic evaluation and response, thereby failing to remove the bottlenecks in a time-bound manner. But beyond that, the biggest advantage of the interface framework is a de-compartmentalized multilayered approach to target the bottlenecks. The interface framework has been built around the traditional stakeholders and consists of the health department, the Police department, the Food and Drug Administration Department, and the Department of Excise and Revenue.

Key components of interface framework: (BASIC)

• Build capacity.

• Accountability, transparency, mutual trust, and sustainability.

• Strategizing interdepartmental coordination/workforce to develop a comprehensive, integrated approach.

• Increasing visibility of effectiveness and efficiency through innovation.

• Creating leadership.

Details of the interface framework

Message from the framework to the stakeholders

The notion of responsibility is essential, and it necessitates strong leadership. The core issue in monitoring and evaluating indicators and outcomes is measuring performance. Monitoring and evaluation methods are required to ensure the creation and implementation of population-based initiatives at all levels. The implementation may also require a forward movement in identifying the specific role of primary care physicians in the framework [Table 3]

Table 3.

Message from the framework to the stakeholders

Why do we need this?	We need to put in place a self-sustaining mechanism to promote tobacco reduction or to reduce violations.
How much do we need from you?	Commitment for the sustenance of the efforts for effective implementation with constant monitoring.
What happens if we do not get it?	This will reduce our chances of implementing the guidelines and envisaging reduced tobacco use in the state.

Terms of Reference of the framework

Scope

The framework looks beyond enforcement. It attempts to identify processes strengthening the scope of execution of the enforcement and awareness, mutually capable of strengthening tobacco control efforts. Enforcement is an important component within the scope of the framework, but so is leadership, capacity building, and innovation. The framework is expected to mandate the need for implementation of guidelines and to follow the processes/procedures dealing with the violations against Tobacco Control law. Enforcement, though critical, has been underutilized, as has been the involvement of community and innovation.

Detailed action points (Enforcement)

Enforcement committee constituted by the Deputy Commissioner at district level under which the enforcement team at every block level in each district is under the supervision of their respective sub-divisional magistrates to deal exclusively with the enforcement function and to guide the activity in the region. In addition, an officer from every enforcement team will be nominated as Block Enforcement Nodal Officer for dealing and coordinating directly with the enforcement committee.

• This team will be entrusted with the seizure of banned tobacco products and issueing challans for any violations against tobacco control.

• The enforcement squad should check with all the municipal and panchayat authorities for any details regarding the unauthorized selling of tobacco products and for any complaints received by them.

• The enforcement squad must organize “Enforcement Drives” for wide publicity and to spread awareness at the ground level.

• The Enforcement Committee may receive complaints either manually, through any helpline number, or social media.

• The complaints received should be examined within a week, after which an enforcement committee must conduct surprise/random site inspections or fortnightly reviews on enforcement actions before taking any strong action against the violator and any tobacco vendor for any offensive action.

• The Enforcement team should share details of the unauthorized tobacco vendor with the registration authorities and Enforcement Committee.

• The Enforcement Committee may levy penalties or take action for the imprisonment of offenders for repeated/consecutive offenses.

Detailed action points (Community)

• Enforcement and other officials should meet the local community on a routine basis.

• The inputs from the community should be a part of a dynamic process of enforcement and challan.

• Involvement of the community in creating tobacco-free zones

• Involvement of community in identifying priority public spaces and areas for action

• Involvement of the community in the utilization of funds collected through challans in preventing tobacco use as well as in de-addiction and rehabilitation

• Creating a community workforce like a youth forum/club to engage the community in implementing a tobacco reduction strategy.

Detailed action points (innovation)

• Create an accessible, visible, efficient, and easy-to-use tool or platform for delivery of the message, collection of data, and capability of integration with the dynamic nature of tobacco control strategies planned from time to time.

• Linking the tool/platform to existing identifiable like Aadhar will help the tobacco control strategists to enter into a domain of auto-analytics and course correction.

Conclusion

The limitations in achieving stated objectives under the tobacco control program require to be addressed by using a framework. The Multi-sectoral implementation interface framework (MIIF) is ideally suited to deliver on this requirement.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.