The eminent threat posed by smoking remains to be a global concern. Despite the relative decline in smoking prevalence among Filipinos, the Philippines still has high morbidity and mortality rates of tobacco-related diseases. The passage of Republic Act No. 10643 or the Graphic Health Warnings Law brought a new light in the Philippines’ tobacco control saga. Much of the perceived benefits of the said law together with the Sin Tax Reform Law of 2012 are yet to be felt in the coming years. Hence, it is imperative to look at various stakeholders who are keys to the success of tobacco control measures.
Stakeholders are actors that may have direct impact on a policy issue or indirectly affect it by strengthening or weakening the authority of policy makers and influencing the implementation process (Durham, Warner, Phengsavanh, Sychareun, Vongxay, Rickart, 2016). Understanding stakeholders’ perspectives do not only inform decision-makers in designing and implementing effective and sustainable policies but also assists in consensus building.
This paper presents a stakeholder analysis to identify relevant actors, their interests, and influence on the tobacco control policy process of the Philippines. This stakeholder analysis seeks to better understand various factors that determine the acceptability, feasibility, and eventual success of the implementation of this tobacco control policy. Finally, this analysis can provide (1) input to other analyses, and (2) a basis for developing strategies or action plans to manage stakeholder concerns, increase support for the policy, or guide the implementation and/or improvement of the policy.
This paper gathered and synthesized information about policy actors and their interests, position for or against the policy, degree of influence, and available resources through the stakeholder analysis approach. It was guided by Kammi Schmeer’s (1999) Guidelines in Conducting Stakeholder Analysis which has the following eight steps: 1) Planning the process; 2) Selecting and defining a policy, 3) Identifying key stakeholders; 4) Adapting the tools; 5) Collecting and recoding the information; 6) Filling in the stakeholder table; 7) Analyzing the stakeholder table; and 8) Using the information. Both primary and secondary sources of data were utilized. Using the gathered information, all potential stakeholders were identified. However, due to limitations of time and resources, a list of priority stakeholders was developed.
Few secondary information on priority stakeholders is available. Hence, an interview with these priority stakeholders was planned to gain more accurate information on their positions, interests, and power. Letters of request for an interview together with an interview guide were sent to stakeholders’ office/s via e-mail and courier with follow-up correspondence via e-mail and phone call. Only a few responded to the request and most of them were not available for interview. As a result, majority of the information that were used in this analysis came from secondary sources of information.
To allow for comparisons and analysis, information was first translated into the stakeholder table (See Table 1). This involved 1) determining the stakeholder’s position, interests, and alliances; and 2) creating a power index for each stakeholder. Once the table was complete, an analysis was conducted which focused on comparing information and developing conclusions about the stakeholders’ knowledge, interests, and positions on the policy issue. A power/leadership analysis was subsequently conducted to determine each stakeholder’s ability to affect the policy process.
Knowledge of the policy issue
The stakeholder analysis identified key stakeholders who can influence the tobacco control policy process in the Philippines. These included the Department of Health (DOH), national policy makers in the Congress, several interest & anti-tobacco groups, Philippine Tobacco Institute (PTI), Southeast Asia Tobacco Control Alliance (SEATCA), and the World Health Organization (WHO), among others. The policy makers are the key decision-makers, yet the influence of other opinion leaders such as SEATCA and DOH is also deemed significant.
All stakeholders appear to be quite knowledgeable and express interest in the GHW policy. The majority of the stakeholders indicate their clear support for the policy. Anti-tobacco groups understand that the GHW law is a tobacco control measure that seeks to curb tobacco consumption and improve health outcomes among Filipinos.
The managing director of HealthJustice Philippines strongly supports this policy and believes that “Tobacco use is an issue of social justice. It is the poor who suffer the most from tobacco addiction, and it is they who need to understand its consequences the most. Graphic health warnings will most effectively convey the harms of tobacco use and eliminate communication and literacy inequalities among our country’s people.”
FCAP’s Tobacco Control Technical officer explains that these “pictures on packs are the most effective means of showing the harms brought about by tobacco abuse, causing premature death and diseases, including cancer.” This was further supported by the President of NVAP saying, “it may help reduce the number of victims of tobacco like us. Let us help save lives.”
The Philippine Tobacco Institute (PTI) also have a good knowledge of the policy. However, it is often recognized as the primary opponent of tobacco control policies. As such, communicating or advocating the objectives and tenets of the country’s tobacco control policy could not possibly reduce its opposition.
Resources, support, and power
Stakeholder power is the influence a stakeholder has over the policy – that is to either support or block the desired change. Most of the stakeholders were supportive of GHW as a tobacco control measure but their influence differed. WHO, an international stakeholder, had high power and therefore was in a position of great influence. It explicitly supported the policy. It was able to effectively mobilize its vast resources to forward the policy as well as influence the process.
“Having these visible pictures so that people really understand the fact that smoking kills is very important and incredibly powerful. Stopping people from taking up smoking and encouraging smokers to quit saves lives and saves money that can be spent tackling other health challenges. We continue to work closely with the Government of the Philippines and strongly support their pioneering work in the country to end tobacco use,” said a WHO Representative in the Philippines.
The DOH seemed ready to assume leadership role in this tobacco control policy. Some stakeholders perceive the DOH as having extensive power to help forward the policy and ensure its effective implementation. Interest groups, anti-tobacco groups, and the Department of Health (DOH) eventually established a support cluster.
Through the leadership of the DOH, this support cluster used their combined resources and power to affect the policy process primarily by framing GHW as a health policy through sector engagement, press releases, press briefings, and other activities using various media. Combining the resources of interest and/or anti-tobacco groups with the power of the DOH to influence the decision-making of policy makers was an effective strategy to forward their unified agenda.
Majority of the stakeholders support, in principle, the policy change. Stakeholder support is an important factor in determining the success of a policy intervention. The high level of support and agreement of international organizations, DOH and interest groups could be linked to the potential benefits of the policy. These benefits – decreased tobacco consumption and decreased morbidity & mortality of tobacco-related diseases – were all recognized and identified by these supportive stakeholders. However, stakeholder views differed with respect to the specific provisions in the law such as (1) size and placement of the graphic warning, and (2) preparation and adjustment period for tobacco product manufacturers and retailers.
While there seems to be a strong political will from the DOH leadership to sustain the measure, there is certainly room for some resistance to change. Many of the stakeholders have identified PTI as a stakeholder that actively opposes GHW as a tobacco control policy. While this opposition was made apparent by PTI in the past, it eventually expressed moderate opposition to the policy during the policy formulation phase when it realized that the enactment of the policy was inevitable.
As the sole group of opponents with the intention to protect their commercial interests, tobacco companies effectively used their power to challenge, discredit, and obstruct the implementation of effective tobacco control measures such as the GHW Law. Due to their overwhelming resources and ability to effectively mobilize these, PTI has the capacity to hire the best law firms for their legal defense pitted against underpaid government lawyers with a ton of caseloads.
Research conducted by anti-tobacco groups showed that these actions included (1) demanding a seat at government negotiating table, (2) drafting and distributing sample legislation that is favorable to the tobacco industry, (3) attempting to bribe legislators, (4) financing government initiatives to gain favor, (5) using tobacco farmers as ‘front groups’, (6) and defending commercial profit (HealthJustice Philippines, 2014).
One key policy maker who hails from one of the tobacco-producing regions in the country has been classified in this analysis as a moderate opponent. He has previously expressed concern about the effect of what he called the “burdensome requirement” on the tobacco industry which is a major revenue source of the government. Another key policy maker, however, sided with the support cluster of DOH and anti-tobacco groups citing the economic cost of smoking and the potential positive effects of tobacco control to the Filipino community. They have presented that the perceived benefits of tobacco control outweigh the negative effects on government revenue, if any.
Another concern of many stakeholders is the interference of the tobacco industry in the implementation of tobacco control policies. The PTI has a long history of opposing tobacco control measures. In 2014, PTI successfully reduced the size of originally proposed graphic health warning labels on cigarette packs (SEATCA, 2018).
Most stakeholders also do not agree with PTI being included in the Inter-Agency Committee on Tobacco (IACT). Most stakeholders believe that PTI could meddle with decision about cigarette policies of the government by sitting in a government tobacco regulatory body that seeks to regulate their industry. Many of these stakeholders have called on the government to remove the PTI from the IACT.
Finally, the DOH is concerned with the implementation of the policy at the local level. The DOH was primarily concerned about cigarettes sold per stick by vendors or retail stores. Hence, in 2016, the Department tapped local government units (LGUs) to help monitor the full implementation of the law at the street or community level. To date, no policy has been issued to regulate the sale of cigarette products per pack at the community level.
Conclusion and Recommendations
In summary, stakeholders identified the following potential benefits of implementing the policy:
- Decreased tobacco consumption among current smokers
- Prevention of the youth from initiating tobacco use
- Decreased morbidity and mortality of tobacco-related diseases
- Decreased government expenditure on curative and rehabilitative interventions for Filipinos suffering from tobacco-related diseases, and
- Increased fiscal space for the Department of Health earmarked to other public health programs, especially Universal Health Care
Few stakeholders identified several possible disadvantages of implementing the policy:
- Decreased demand on tobacco products
- Decreased government revenue from tobacco tax
- Decreased employment opportunities for tobacco farmers
All stakeholders have good knowledge of the policy and relate it as a tobacco control measure. Some stakeholders with good knowledge and moderate resources clustered with stakeholders who have high power. This support cluster or alliance allowed these stakeholders to maximize combined resources and power to affect policy processes. This support cluster may continue building bigger alliances to increase resources and power to counter greater opposition in the future.
Most stakeholders identified one primary opponent, a group of tobacco companies, who had high power and influence on the policy process. On the contrary, this group of companies has expressed moderate opposition of the policy. Due to its good knowledge of the policy and vast resources to forward its opposition, it would render much difficulty in moving the group to fully support the policy. More importantly, its high power enables it to steer the implementation process in favor of its economic interests. In order to lessen the effect of this power, groups and individuals supportive of the policy should convince key opinion leaders in the Congress to minimize the involvement of PTI and its allies on government tobacco control policy processes.
Lessons from this stakeholder analysis are useful for informing the implementation of the policy. Consultation of stakeholders during the policy formulation phase and inclusion of their ideas promote support to the policy. There is a need to involve other stakeholders in the local level where the actual implementation is. Involvement of the local stakeholders in implementing the policy could increase the number of drivers who could play key roles in sustainability.
Research may be needed to demonstrate the potential reductions in tobacco consumption associated with the retail sale of tobacco products in packages with graphic health warnings and allay stakeholders’ concerns on the sale of these products at the street or community level. Examining and documenting the legitimate concerns among stakeholders involved in tobacco control policy and/or consumption can provide insight on the reasons why it is not effectively implemented or why it doesn’t rip the benefits it intends to deliver. It can help in developing a communication plan around other issues identified by stakeholders as well as in developing a plan of action for improving the policy and/or its implementation.
Given the nature of policy making in the Philippines, a more detailed and up-to-date stakeholder analysis may help track shifting interests and perspectives so that policy strategies can be modified to achieve intended policy changes.
There is no doubt that the passage of the GHW law greatly benefited from strong political support, leadership from DOH, and advocacy-driven action by anti-tobacco groups. The country’s experience may not be comparable with the experiences of other countries that have implemented similar reforms. The tobacco industry’s power remain a significant influence in the tobacco control policy process of the Philippines. However, the experiences with the GHW policy process in the country has established a strong foundation for future reforms, especially in tobacco control.
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