1. UNDP and General Obligations of the Framework Convention on Tobacco Control
Douglas Webb
HIV, Health and Development Group
Bureau for Development Policy
UNDP, New York

2. Social determinants on which UNDP’s HIV and health work focuses
UNDP works in seven core areas, many of which are social determinants of health
Poverty and inclusive growth
Social determinants on which UNDP’s HIV and health work focuses 1 2
Democratic governance
Crisis prevention and recovery 3 4
Gender
HIV, Health and Development 5 6
Environment and energy 7
Capacity development

3. Starting points
Tobacco work is new to most of the UN system, so we are in the early stages of a coherent response
UNDP’s work on social determinants of health is now addressing non-communicable diseases, building on a platform of HIV and AIDS work
UNDP’s mandates are only very recently agreed

4. Many structural determinants impact multiple health conditions at the same time
contributing to
Disease/ condition1
Urbanization, migration
Malaria, TB, leishmaniasis, plague, intestinal helminthiasis
Anopheles mosquito, malaria vector
TB bacillus
Conflict, displacement
Malaria, measles, diarrhea
Climate change
Cholera, schistosomiasis, vector-borne diseases (e.g., river blindness, sleeping sickness)
It will almost never be cost-effective or strategic to address a distal or high-level structural influence for the sake of a single disease outcome. If you are trying to prevent the spread of HIV and have to choose between male circumcision and promotion of girls education, the former may give you more of a result in the short term, per dollar invested, as measured in terms of impact on HIV incidence alone. However the latter may have multiple and longer term health and development benefits, which in addition to reduced HIV risk, might include reductions in adolescent pregnancies, smaller and healthier families, and greater opportunities to contribute to and benefit from economic and social development.
So we should not be addressing key structural determinants just because of single disease outcomes. As with promoting girls education, many are important issues in and of themselves, regardless of their contribution to ill health. And many structural determinants impact multiple health conditions at the same time – so structural interventions may lead to multiple positive health outcomes.
As I will discuss later, we shouldn’t fall into false dichotomies or choices. Countries can and should select an appropriate mixture of strategies that respond to their own health and development needs and resource constraints.
Woman with river blindness
Income inequality
Avg life expectancy, infant mortality, accidents, smoking
1Not exhaustive list; examples only
Sources: Pronyk P. at Columbia University,WHO, McMichael T.,Sharma VP; Farmer P., Raviglione MC, Howarth JP, Dick B., Wilkinson RG, and others

5. Structural interventions at a policy level were critical in reducing smoking in the United States
Policy intervention(s)
Advertising restrictions
Public awareness campaigns
Cigarette taxes
Anti-smoking legislation
Smoking levels dropped from 52% to 25% over past 30 years
8 cent cigarette tax alone caused 2 million adults to stop smoking and prevented 60,000 teens from starting
One example of the power of this approach comes from tobacco control. Decades of health promotion investment to discourage smoking made relatively little impact on tobacco use in the United States.
Once the State started using ‘upstream’ or structural approaches, however, we began to see dramatic results.
Source: McKeown T. et al. 1975, US Centers for Disease Control 2000

6. UNDP Mandate
UNDP works in areas related to social determinants of health, including non-communicable diseases
(a) decision of the Conference of the Parties FCTC/COP/4(17) in relation to cooperation for implementation of the Convention.
(b) the Report of the Secretary-General on Ad Hoc Inter-Agency Task Force on Tobacco Control (July 2012)
(c) ECOSOC resolution E/2012/L.18 on the United Nations system-wide coherence on tobacco control (July 2012)

7. ECOSOC Resolution: United Nations system-wide coherence on tobacco control
Encourages the Ad Hoc Inter-Agency Task Force to promote effective tobacco control policies and assistance mechanisms at the national level, including through the integration of the World Health Organization Framework Convention on Tobacco Control implementation efforts within the United Nations Development Assistance Frameworks, where appropriate, in order to promote coordinated and complementary work among funds, programmes and specialized agencies;

8. Article 5.1 Discussion paper for the COP being developed by UNDP and the FCS
Integrating tobacco control into national health and development planning strategies and frameworks and UNDAFs: experience and best practice recommendations
Articulate the case for the integration of tobacco control plans into national development plans and UNDAFs
Provide an overview of current extent of integration of tobacco control plans into national development plans and UNDAFs
Provide collated information about best practice and recommendations for national action from current experience
Provide recommendations for action at national and global level
Provide list of information resources

9. Increased support provided by UN country teams for the same.
Desired outcomes
Increased action at national level to integrate tobacco control plans in national development plans and UNDAFs through strengthened multi sectoral commitment.
Increased support provided by UN country teams for the same.

10. Article 5.1 in Africa
34/41 Parties have some aspect of tobacco control incorporated into national plans/strategies
15 (37%) Parties have an operational comprehensive multisectoral national tobacco control strategy
17 (41%) Parties have included tobacco control into national health plans (out of which 2 also have multisectoral plans)
13 (32%) Parties have referred to any aspect of tobacco in other national strategies (out of which 9 parties also included tobacco in either multisectoral or national health plans)

11. Article 5.1 Globally
Of the 120 of the 174 FCTC parties for whom data is available from the 2012 reporting cycle:
74/120 (62%) indicated a comprehensive multisectoral national tobacco control strategy.
43 (36%) of parties reported tobacco control being incorporated in national health plans and
21 (18%) parties reported including tobacco control in other national plans.

12. Non Communicable Diseases and tobacco control
11 countries have integrated NCDs into their latest UNDAFs
3 countries have integrated any mention of tobacco into their latest UNDAFs (Burkina Faso, Djibouti, Mauritania)
Only 1 specifically mentions FCTC (Mauritania)

13. Case Study: Ghana

14. Case Study – Ghana;
Planning Challenges
Lack of knowledge and representation of FCTC issues in the planning process
FCTC seeks to prevent a tobacco epidemic from occurring in Ghana – not to deal with an existing epidemic – therefore it is not seen as a priority
Development partners and their priorities still have a strong influence on the process. FCTC is not yet a development partner priority in comparison to HIV/AIDS, malaria and TB.
Adapting health plans to development planning formats and M&E created unintended structural problems

15. Implementation Challenges
Case Study – Ghana;
Implementation Challenges
Lack of funds to produce legislative instrument to progress the recently passed tobacco control bill
Lack of funds to promote tobacco control messages down to the district level
No further external nor internal funding allocated to tobacco control as an outcome of the process

16. Case Study – Ghana; Critical Enablers
Planning Key enablers
The thorough GHS health planning process that builds from district level up to a multisectoral national Health Summit to identify Health priorities and objectives
Including NCDs in the Health Plan, facilitated including NCDs in the National Development Plan.
Although FCTC and tobacco control not mentioned specifically in NDP, inclusion of NCDs facilitates including FCTC implementation in operationalizing the NDP

17. Implementation Enablers
Case Study – Ghana;
Implementation Enablers
A National steering committee for tobacco control including, Ghana Health Service, Ghana Education Service, media and the NGO coalition
Media has been educated and sensitized to report on tobacco control.
Health care staff has been given public education through media outlets; including preparing an educational video clip.
Capacity building in public health schools and medical schools has been initiated in order to make the future health workforce advocates of tobacco control (facilitated by FCS and WHO)

18. Case Study – Ghana;
Recommendations
The Government side needs to come to a consensus on national priorities; and donors and other development partners should be more flexible and responsive to the country needs and priorities. (whether FCTC or other health issues)
NCDs should get their own section in the plans, not come under a sub-heading
Donors and partners should look beyond specific disease priorities to more broad health service issues; it’s not enough to have the vaccines must also have the means to deliver them to people

19. Emerging UN wide support

20. Health or Tobacco?

21. Areas of collaboration within the Convention
Article of the WHO FCTC
Agency
Specific action
Article 5
(General obligations)
UNDP
Take into account requirements of Article 5 in UNDP's country level role as convener and coordinator, where appropriate and under its governance programmes.
Article 6
(Price and tax measures)
World Bank
Support countries with the design, implementation and evaluation of tobacco tax issues, upon countries demand. This effort would complement ongoing efforts by WHO/TFI in this area.
Collaborate with the WHO FCTC secretariat to assess the possibility of having joint Needs Assessment missions with regards to Article 6 issues.
Research to assess the potential regressivity of tobacco taxes as well as the impact of tobacco use in poverty.
Research on the effects of tax incases on tobacco economic agents, particularly farmers as well as illicit tobacco trade.

22. Areas of collaboration within the Convention
Article 8
(Protection from exposure to tobacco smoke)
ILO
Implement the ILO SOLVE programme (an interactive educational program designed to assist in the development of policy and action to address health promotion issues at the workplace) to promote smoke-free workplaces.
Article 12
(Education, communication, training, and public awareness)
UNESCO (International Bureau of Education)
Include tobacco awareness in school curriculums and teacher trainings.
Promote smoke-free schools.
World Bank
Integrate tobacco in education programmes within Trust Funds.
Article 15
(Illicit trade in tobacco products)
WCO
Provide support to the negotiations of the Protocol on Illicit trade.

23. Areas of collaboration within the Convention
Article 17
(Support for economically viable alternative activities)
FAO (Agriculture Department)
FAO (Economic and Social Development Department)
Provide technical support in tobacco growing areas for sustainable crop production intensification with the goal to diversify production, reduce environmental and health impact and reduce the risks of tobacco growers in depending on one single product (subject to funding).
Update of the world tobacco production and market situation; (subject to funding: minimum budget required 50,000$).
UNCTAD (Special Unit on Commodities (SUC), Division on Trade in Goods and Services, and Commodities (DITC))
Collaborate with key partners including international agencies to conduct research and analysis of the tobacco supply chain analysis from the ‘farm to the cigarette’.
Policy review of tobacco producing developing countries (include diversification options).

24. Areas of collaboration within the Convention
ILO
Expert input to the WHO FCTC Working Group on Articles 17&18.
Updating a 2003 study on the state of employment in the tobacco sector globally (forthcoming November 2012 report).
Develop economic & labour market analysis; toolkit on agricultural cooperatives; training material for establishing small enterprises; local development; value chain development tools (rural): rural skills development tools, etc.
Develop research on diagnostic and scope studies on decent work, food security and alternatives for tobacco growers.
Promote social dialogue to support economically viable livelihoods for tobacco growers and workers
UNEP
Promote green economy framework for economically viable alternatives for tobacco growers and workers
WIPO (Development Agenda, under the thematic project “Project on intellectual property (IP) and Product Branding for Business Development in developing countries and least developed countries (LDCs)”)
Provide through Technical Assistance and Capacity Building support to actions by governments to help farmers move to tobacco alternative livelihoods.

25. Areas of collaboration within the Convention
Article 18 (Protection of the environment and the health of persons)
UNEP
Technical assistance related to :
Sound management of chemicals in tobacco growing
Environment audit, impact assessment of tobacco growing
Integrating tobacco related issues within national environmental protection programmes
Articles 20, 21& 22 (Research, Surveillance and exchange of information) and (Reporting and exchange of information)
UNCTAD (International Investment Agreements (IIA) Section, Division on Investment and Enterprise (DIAE))
Share database and information on:
Trade data (all bilateral official trade data at HS-6 digit).
Border measures: import tariffs at 6-digit, tariff rate quota (TRQ) and other (e.g. domestic support).
Non-tariff measures.

26. Areas of collaboration within the Convention
UNDP
Integrate WHO FCTC/NCDs reporting into the Human Development Reports (HDR).
UN Women
Ensure gender sensitive data collection, in particular for surveillance, survey including data on women's role in tobacco products.
Gender specific strategies to ensure women are equally informed about their rights.
World Bank
Cooperate with WHO for harmonization of tobacco questions into surveys such as Living Standards Measurement Study (LSMS) and LSMS-like surveys and provide input to existing tobacco questions in the WHO surveys.
Cooperate also with the Convention Secretariat for analyzing the data collected from the reporting instrument.

27. Potential UNDP roles
Some specific opportunities for UNDP in tobacco are emerging
UN system coordination (RC) and UNDAF integration
Post-2015 development agenda
Support to National action plan development
Integration of tobacco/FCTC/NCDs into national development planning
Support to national governance structures on tobacco/NCDs
Anti-corruption and regulatory independence
Intellectual property/TRIPS, trade, and plain packaging
Strengthening law enforcement, justice
Strengthening local government-municipal programming
CSO engagement
Gender and tobacco, human rights

28. Principles of strategies
Principles for tobacco strategy development 
strategies need to become more fit for purpose and integrated –integrate the tobacco strategies into wider health and development strategies;
A national strategy that is shorter, higher level with emphasis on planning processes that are smarter and lighter on people’s time and money
Strategies and implementation plans should aim for results, prioritizing interventions and represent value for money, determined by the effectiveness, efficiency and equity of the programme that is planned. In particular, strategies and implementation plans must prioritise halting tobacco use initiation and not only invest the bulk of resources in treatment.
Strategies should give more effort and attention to implementation and review, linking interventions to expected results, and then monitoring progress
Developing indicative, medium term budgets with realistic costing of major programme areas, together with ensuring the level of investment is closely aligned with evidence of ‘what works’ and development of scenarios for what interventions are to be prioritised in low, medium and high level funding scenarios

29. Organisational options
Tobacco
HIV (TB and Malaria)
NCDs

30. Conclusions A multisectoral response is essential
Experiences of Article 5 implementation are now being gathered
Only One third of parties in Africa have a comprehensive multisectoral strategy on tobacco
Around one third of parties mention tobacco in other development or sector plans
Experience suggests that integration of FCTC into other development instruments leads to greater implementation
UN Mandates are recent so work can now accelerate
UN partners can assist if the demand is there at country level
Coordination structures are to be assessed to determine efficiency of different models
There is political capital in tobacco control, isn’t there?