Table 1 Summary of other identified barriers and opportunities to developing and implementing marketing restrictions

Nutrition actor network effectiveness

- Absence of actors collectively advocating for change (e.g. leaders, institutions) (2 GOV, RES, 3 IO, DR) vs examples where this has occurred for alcohol restrictions (GOV), MAP development (2 RES), and Multi-sector Nutrition Plan policy community cohesion (IO)

- Lack of a forum or network where actors come together to address NCDs (GOV, MED, RES)

- People, social leaders need to be vocal and consistently advocate and press for change (RES, CSO)

- Based on legalising abortion, need ground up push so Government cannot say no (RES)

Strength of leadership

- No strong leadership on NCDs, and even less on risk factors for NCDs (GOV, IO)

- Health Minister has failed to take a lead; if there is a powerful leader, things get done (2 GOV, RES), e.g. during MAP development (RES) under the previous minister (IO)

Civil society mobilisation

- Lack of civil society debating and lobbying on NCDs (IO, GOV); NGOs should provide suggestions, put pressure on government to push for policy formulation (2 MED)

- Civil society proved important in resisting private sector interference, such as in tobacco (GOV), and in pushing for stronger action from the Nepal Press Council on media content (MED). One CSO respondent considered NGO advocacy along with that of clinicians talking about the rise in the NCD burden in Nepal critical to the government formulating the MAP.

- Nepal NCD Alliance talking about the need for action on NCDs (RES), and various other civil society, such as the Nepal Heart Foundation and Nepal Diabetes Society, but they are active in their own spheres, not active as a coordinated group (CSO)

Strength of institutions

- Lack of multisectoral coordination for the MAP across Ministries (RES, 3 GOV, 2 IO) with for example the high level NCD Committee having only met once since 2014 (IO)

- Inadequate government structures (2 RES, 2 IO, GOV, CSO), even though a designated structure for NCDs has been established within the MoHP post federalization (RES)

- MoHP has the power for bilateral action, but potentially lacks mandate for multisectoral action (RES, GOV); but some consider that MoHP should lead (GOV, RES)

- No one leading on MAP implementation (but everyone is involved), unlike the Multi-sector Nutrition Plan which was led by the National Planning Commission (IO); National Planning Commission should be the executing body for the MAP as many elements outside the control of health, similar to its role in nutrition (2 GOV, IO)

Effective vertical coordination

- Lack of vertical coordination for the MAP between policy responsibility at the MoHP and implementation by the Department of Health identified, noting that this was not the case previously, potentially due to changed leadership (RES)

- Need for regional cooperation to deal with cross-border issues (PS)

- Previously demonstrated successful vertical coordination within and external to government in iodisation efforts to address goiter (PS) and in food standard setting (GOV); but also inadequate vertical coordination in implementing tobacco control laws where for example tobacco officers regulating the law do not understand their roles and responsibilities (GOV)

Societal conditions and focusing events

- Attention diversion at time of the MAP (e.g. the earthquake and federation reform and lack of stability) could have impeded development and implementation (2 GOV, CSO)

- Crowded government agenda in health, including the unfinished Millennium Development Goals and the Sustainable Development Goals (IO)

- Cross-border media and imports of food from India and China (CSO, PS, IO, DR) create issues in regulating (MED), including due to Nepal’s World Trade Organization membership (MED)

- Junk food advertisements from India, e.g. influence of Delhi life, is contributing to changing social attitudes among school students who ridicule home-made foods (GOV)

- Now is the time to act (MED), as overweight and obesity has more than doubled in the last 15 years, and access to and use of unhealthy foods has increased (IO, GOV, RES)

Ideology and institutional norms

- Prevailing beliefs of the need to have sugar in diet to survive (CSO) or that children should eat noodles to ensure they are not malnourished (more common in rural areas) (GOV)

- May encounter public resistance in trying to restrict items like biscuits and noodles that have meaning for common people / where strong beliefs around nutrition (PS, DR)

Credible indicators and data systems

- 5-yearly NCD Risk Factors STEPS survey established to provide clear data and indicators on NCDs (IO, GOV, RES)

- Food consumption surveys have not been undertaken to distil eating patterns in Nepal – should be done, but there is insufficient capacity (GOV); and only scattered efforts on indicators specifically on the degree of the problem of marketing unhealthy foods to children (DR)

Internal frame alignment

- Some recognition among those involved in the policy process of the importance of NCD prevention (and regulation) rather than just a treatment, but they consider (mistakenly) that the most effective approach is behaviour change (RES, CSO, IO, GOV)

- Others considered that structural policies, including marketing restrictions, are the right approach to achieve the most progress, alongside behaviour change (RES, CSO)

External frame resonance

- Framing marketing restrictions as an issue of child rights could have the power to convert to action / draw the government’s attention (2 RES, 2 MED, CSO)

- Public consider taste and quality of high salt noodles to be more important than health concerns, a view shared by Nepalese industry (GOV)

Strategic capacities

- Evidence of engagement of stakeholders in policy-making, such as through consultation in MAP development (GOV), and facilitating solutions via engaging communities and industry by other key governmental departments or regulators such as the Department of Food Technology and Quality Control via subcommittees (2 GOV)

- Lack of strategic capacity indicated: when the MAP was being developed given no one briefed the Chief Secretary and the Prime Minister’s Office on what was expected from them to enable implementation (RES); the government needing to convince the relevant stakeholders – media, advertisement association, and Nepal Press Council – that advertisements are not just for money generation, but also for awareness creation (MED)

Financial resources

- Insufficient funds (DR, CSO), with money from the tobacco tax not being spent on NCD prevention, but only on treatment (CSO)

- Government’s expenditure on NCDs in the health budget is too low (< 6%) (RES), and it should go up; should spend funds from alcohol, tobacco, and other taxes on NCDs (IO)

- Ministry of Finance needs to be engaged to ensure sufficient resources (IO, RES)

- May be fiscal space for policy development in the future (IO)