Table 2 Strategic action recommendations for promoting evidence-informed policy responses to restrict marketing of unhealthy foods to children in Nepal

Based on the findings from our interviews and wider understanding of the literature on policy change, we have identified five areas where strategic action is needed to generate political incentives to promote the development, adoption and implementation of effective policies to restrict marketing of unhealthy food to children.

1. Build a multi-stakeholder coalition. Nutrition advocates, researchers and civil society, should develop a multi-stakeholder coalition to generate political incentives to put and keep marketing restrictions on the political agenda, and counter private sector interference. Nepal has a strong history of Government and civil society collaboration on tobacco (an area in which Nepal has shown policy leadership [53]), and it already has a base of support, such as via the Nepal NCD Alliance and Nepal Heart Foundation. Nepal has also experienced NCD policy success when the policy community (e.g. government, international organisations, research institutions and clinicians) cohesively advocated for evidence informed, NCD policy formation, including in implementing alcohol restrictions and the Multi-sector Nutrition Plan. Civil society mobilisation has also been a key factor in overcoming food industry interference or generating government commitment [41] for marketing restrictions in other countries, via communications networks and media [54], providing technical and financial capacity, or acting as “knowledge brokers” [43, 55].

2. Reframe the challenge and use local evidence. A multi-stakeholder coalition could raise the importance of marketing restrictions by:

       a. Framing the challenge (unhealthy food marketing) and solution (marketing restrictions) as protecting child rights to justify government intervention to combat recently introduced but increasingly dominant norms and narratives. The child rights frame was suggested by respondents to have the power to draw the government’s attention and get it to convert words into robust regulatory action. A child rights frame has been advocated for globally to help build political will as child rights are often a government priority [56]. As child rights are enshrined in Nepal’s constitution [57] any regulation of marketing of unhealthy food to children in Nepal could rely on these rights [58] and leverage human rights monitoring mechanisms [55].

       b. Leveraging existing evidence to show that now is the time to restrict marketing, including evidence of Nepal’s growing NCD burden and of the population’s increased access to unhealthy foods. International evidence of the need for and effectiveness of marketing restrictions, including the most effective form of regulation, is likely to be applicable, and was successfully applied in Chile alongside local evidence [56]. Existing tools could also be used, such as the South-East Asian WHO Region’s Nutrient Profiling Model [59] to provide objective criteria for unhealthy food marketing and ensure proportionate regulations [43, 60]. However, advocates will need to support the generation of new evidence to help design effective marketing restrictions (e.g. to better understand the exposure and power of marketing to children in Nepal).

3. Adopt a whole of government approach. The above two actions would help to build political support across the ministries required to develop and implement restrictions on marketing of unhealthy food to children, from the Ministry of Communication and Information Technology to the Ministry of Finance. Brazil’s experience (where the Attorney General suspended a proposal to restrict marketing supported by the ministry of health) suggests whole-of-government support is required [61]. This mirrors experiences in LMICs, where inadequate political administrative support was a barrier to implementation due to governments’ resistance to the hard policy tool of regulating, concern about trade threats, or viewing restrictions as contrary to economic development [41, 47, 55, 62].

4. Appoint a lead institution. An institution with a broad remit should be charged with overseeing policy development and implementation of restrictions via an interagency mechanism. In contrast to the Ministry of Health, the National Planning Commission, with proven experience in multi-sectoral policy execution and high standing among Ministries could more ably deal with the complexity of regulating cross-border marketing, coordinate multi-sectoral action, address competing and norms and narratives, and counter private sector interference. The importance of a strong lead institution was supported by Nepali respondents as well as experience in Thailand where lead agencies needed sufficient authority to operate effectively to implement marketing restrictions [45]. A strong lead institution may also safeguard against any leadership vacuum created by high ministerial turnover, and ensure stronger implementation capacity, including adequate funding and human resources to govern marketing restrictions (reported by respondents and in the literature [63, 64]).

5. International support. The above agenda would arguably be aided by:

       a. A strong international mandate or code for unhealthy food marketing to children (or extension to the International Code of Marketing of Breastmilk Substitutes) - which the Framework Convention on Tobacco Control provided to national tobacco control efforts - has been called for by academics since 2011 [65,66,67] In 2019, experts also called on the WHO Director-General and the UN High Commissioner for Human Rights to develop human rights guidelines on healthy diets, which included a focus on marketing of unhealthy foods to children [68].

       b. In the absence of a global code, greater international financial and technical support for Nepal, including for regional coordination, is needed. It is clear from respondents, and literature from Nepal, the South-East Asian WHO Region, and LMICs that current support is insufficient, including research funding for NCD prevention and control [12, 43, 69, 70]. Such support is a key assumption in Nepal’s MAP [37]. The importance of it has been demonstrated in Mexico which collaborated with the Pan American Health Organization’s task force to control food marketing to children and adolescents [54], and in Fiji, where the WHO provided legal and health expertise to ‘build momentum’ to advance a bill seeking to restrict marketing of unhealthy foods to children [60].