This case study focuses on two school-based interventions that were initiated by the Ministry of Health of Turkey to decrease environmental obesogenic influences on children and adolescents: The Circular for Food and Drink Sales in School Canteens, and the Physical Fitness Scorecard for Health.
The Circular attempts to provide a framework and guidelines for the kind of food that could be sold in school canteens, with the goal of discouraging the sale of high-calorie foods, sugar-sweetened beverages, and other foods perceived as unhealthy
The Scorecard program, which was initially piloted in Ankara and is currently being scaled up nationwide, attempts to encourage increased physical activity among children in secondary schools and high schools through personalized schemes. The case study aims to explore the factors which led the government to focus on fighting and controlling obesity for children and adolescents in schools. The case study focuses on the interventions described above, and examines the obstacles faced during implementation (delivery challenges), the position and engagement of involved stakeholders, and how their position influenced the design and implementation of the interventions.
Confronting Childhood Obesity Rapidly changing dietary habits and decreasing physical activity levels of children and adolescents lead to increased obesity prevalence in the country. These changes are driven by a complex mix of factors
Delivery Challenges: Stakeholder Engagement and Organizational Capacity
The programs have faced a number of implementation challenges, mostly centered around population and stakeholder awareness, stakeholder engagement, organizational capacity, and basic infrastructure. These challenges are being addressed by maintaining the lines of communication with the stakeholders to foster collaboration, by delegating greater responsibility to the implementing actors, and by intensifying organizational capacity building.
Concerning the Circular on the Hygienic Control of School Canteens and of Food and Drink Sales in School Canteens, one significant implementation challenge was the neutral position and weak engagement of some stakeholders (specifically head teachers, teachers, canteen operators, and parents) which affected the public sector’s position vis-à-vis the oppositions from various actors. This low engagement also slowed the dialogue between involved actors, necessary to develop viable solutions to implement the circular in the field.
A second important implementation challenge was the low awareness about healthy nutrition which created several means to bypass the restrictions of the circular thus limiting its intended impact. Through the introduction of the circular, a gap emerged on both the demand and supply side for food and beverage products—another challenge highlighting the necessity to have products that both comply with regulations and meet customers’ preferences. Finally, the monitoring and supervisory roles and responsibilities stated in the circular were additional challenges to be addressed in order to facilitate proper program operation and oversight, particularly in terms of setting effective accountability mechanisms.
For the Physical Fitness Scorecard for Health program, one important implementation challenge is to improve the human resource capacity and skills nationwide to collect and enter data following standard procedures and compliance with the relevant curriculum. Maintaining a robust database infrastructure would ensure proper and reliable data collection, analysis, and interpretation and would support and facilitate future policy design and decision making. Another implementation challenge is related to the sustainability of the program and the genuine commitment and engagement of the teachers as the program success will largely depend on how effectively the program is carried out in the field.
The general lessons of this case study are particularly crucial as they relate to and highly affect the large-scale nature of both interventions.
A first lesson is that enhanced and continuous communication is critical for success. Internally, from the stakeholders’ and implementers’ points of view, this means effective, uninterrupted, and in-depth dialogue. Externally, from the population’s point of view, this calls for intensive efforts to create awareness and thus to lead to behavior change over time. Both of these internal and external efforts will bring about proper engagement and genuine buy-in of the involved parties and will eventually lead to feasible and successful practices in the field.
Another lesson learned is that the programs need to be customized. Therefore, policy design and implementation should take into consideration the country context (based on scientific evidence) in order to have a viable conceptual and operational framework. Here, more stringent and effective dialogue and communications with stakeholders and with the target population highly influences the degree to which the environmental context is understood and duly reflected in policies.
A third lesson concerns making the best use of existing capacity and to be fully aware of the system capabilities and limitations in terms of organization, infrastructure, and subject-matter expertise. Large-scale implementations, such as the nationwide scale-up examples explored in this case study, necessitate proper assessment of existing capabilities and gaps for successful program design and implementation.