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Background: Male life expectancy in the Russian Federation, at 60 years, is the lowest in Europe. Several factors contribute to this situation, but hazardous consumption of alcohol is especially a key factor. Methods: We undertook a stakeholder analysis in a typical Russian region located on the western side of the Urals. Organizations with a stake in alcohol policy in the region were identified by snowball sampling and information on their position and influence on alcohol policy was elicited from interviews with key informants. Their interests and influence were mapped and their relationships plotted. Results: Twenty-nine stakeholder organizations were identified and 43 interviews were conducted with their staff. The most influential actors were the Federal and regional governments, large beer producers and manufacturers of strong alcohols. However, the majority of organizations that might be expected to play a role in developing or implementing alcohol control policies were almost entirely disengaged and fragmented. No evidence was found of an existing or emerging multi-sectoral coalition for developing alcohol policy to improve health. Organizations that might be expected to contribute to tackling hazardous drinking had little understanding of what might be effective. Conclusions: While stakeholders with an interest in maintaining or increasing alcohol consumption are engaged and influential, those who might seek to reduce it either take a very narrow perspective or are disengaged from the policy agenda. There is a need to mobilize actors who might contribute to effective policies while challenging those who can block them.
Hazardous consumption of alcohol is a major factor in the high rate of premature death in Russia,1,2 with non-beverage alcohols (containing 70–95% ethanol) such as medicinal tinctures and aftershaves,3 consumed by about 8% of working age men,4 especially dangerous.5 In January 2006 the federal government introduced controls on manufacture and sales of these products,6 which coincided with a fall in alcohol-related mortality. However, in 2007 many products, especially medicinal tinctures, remained easily available.7 Moreover, vodka remains cheap and easily available (including bootleg vodka), while beer consumption is gaining popularity among young people.
Russia is, however, a federation, and actions are also required at regional level. In this paper, we explore the context of policy making on alcohol in a typical Russian ‘oblast’ (region).
During 2007–08 we undertook a stakeholder analysis in an oblast of 1.5 million inhabitants located close to the Urals. Stakeholder analysis8 encompasses a range of techniques that address the distribution of power in society9,10 and patterns of formal and informal relationships that shape policy agendas,11 in which policy entrepreneurs invest resources to bring about policies they desire, while other stakeholders, who remain uninvolved, cede influence.12
A stakeholder is any person or organization that has an interest and the potential to influence an organization, policy or project.13 Stakeholder analysis seeks to understand their interests in the issue, the positions they take on particular policies and the strength with which they hold them and their real and potential influence, which means that it is possible to understand who is supportive, opposed, neither supportive or opposed and marginal.
Snowball sampling was used, beginning with obvious stakeholders14 and information was obtained from semi-structured interviews. Those interviewed were asked to suggest others that might be stakeholders and this process continued until no new subjects were identified.
The analysis explored attitudes to a range of standard alcohol policy options, including taxation, availability, minimum ages, regulations on production and sale of non-beverage alcohol, advertisement and promotion and enforcement of drink-driving legislation. Stakeholders were asked to reflect on their potential to influence policy and their relationships with other stakeholders.
All but five interviews were conducted by a single researcher (AG), informed by ongoing research on alcohol in Russia, taking contemporaneous notes supplemented by observations immediately afterwards. Findings were discussed subsequently with other team members. Informed consent was obtained with the assurance that comments would not be attributed to individuals.
The potential of interviewees to influence alcohol policy was assessed according to their willingness to engage in policy discussions within the scope of their normal activities, their ability to be heard in those discussions and their ability to influence other relevant actors. We particularly sought evidence of where they had made an impact on previous policies. Our judgement of the strength of each stakeholder and the interrelations among them represents a synthesis of their own perceptions and how others perceive them. We differentiated personal views of individuals from those of their organizations.
We then constructed an influence map. This is a series of concentric ellipses in which those with the greatest influence on policy are in the centre, with entities having less influence on the periphery. Linkages between different entities are represented by lines, the thickness of which reflects the intensity of the relationship, with the legend describing the nature of these relationships and influences.
We were not able to interview a representative of Roszdravnadzor, but included this organization in the influence map based on our knowledge of its role in alcohol policy and on information provided by other stakeholders with which it interacts.
We report the views of organizations with a presence in the oblast, although we also took account of stated policies and positions of federal and international entities where relevant. Twenty-nine stakeholder organizations were identified (table 1), from which 43 representatives agreed to be interviewed. Subjects were mostly the most senior person in the organization but, in a few cases, they nominated deputies. We were unable to secure access to the producers and distributors of non-beverage alcohol.
Positions of stakeholders on measures to reduce alcohol-related problems and the strength with which they hold them are shown in table 2. Although almost all indicated either support for or opposition to more effective action, few articulated strong views. The exceptions were some federal agencies, who supported stronger action, and some producers who opposed it.
All major stakeholders acknowledged alcohol as posing a serious problem. Oblast and municipal officials stressed the importance of effective action and the need for a broad range of policy measures. However, each saw the problem from their own perspective. Thus, the Oblast Ministry of Internal Affairs stressed the problem of counterfeit alcohols, especially illegal vodka imported mainly from the northern Caucasus and which the Ministry estimated comprised at least 40% of all sales. In contrast, the Health Ministry stressed the adverse health consequences among working-age men, while other health sector organizations stressed on the problem drinking among adolescents and children as young as seven, and the importance of non-beverage alcohols and illegally produced spirits. The education sector also focused on problem drinking by young people but saw a lack of recreational facilities, high level of social disadvantage and parental drinking as key factors. Rospotrebnadzor, the trading standards organization, expressed concern about poisoning by non-beverage and illegal alcohols.
Local spirits and beer producers saw the problem concentrated among adolescents, with a lower age of initiation of drinking. They were especially concerned about non-beverage alcohols, illegally produced spirits and alco-pops, all of which they perceived as competition.
Manufacturing industry was concerned about drinking in the workforce, a view echoed by the Oblast Labour Committee.
Views from the pharmaceutical sector were contradictory: the representative body acknowledged the easy availability of beverage alcohols but denied being a major provider of cheap alcohol in medicinal tinctures, while individual pharmacists conceded that this was the case.
Other stakeholders such as non-governmental organizations and the church had less specific concerns.
The Ministry of Internal Affairs and Rospotrebnadzor had only a general perception that it would be good to reduce alcohol poisonings, drunk driving and alcohol-associated crime. Where Rospotrebnadzor had acted ostensibly on health grounds, for example, by banning import and retail certification of Georgian and Moldovian wines, this was viewed as reflecting Russian foreign policy imperatives.
Producers of local spirits argued that child and adolescent drinking should be addressed first, as this laid a basis for later problem drinking. They accepted that as producers they had a responsibility for preventing underage drinking, but conceded that they were doing little about it. In contrast, they stressed that adult drinking is a personal choice. They expressed support for measures that might further reduce the availability of illegal and non-beverage alcohols as well as the prevention of alcohol abuse among their own workforce. They were opposed to federal moves to increase excise taxes, not least because they were sceptical about their scope to compensate for lost revenues by increasing prices, as they believed that high taxes would reduce their market share with people turning instead to illegal and bootleg alcohols.
Beer producers took a similar attitude, but supported any policy that they felt would increase consumption of their products. They had welcomed the crisis that beset the alcohol market following the 2006 legislation, which created a transient shortage of spirits. Like the spirits manufacturers, they would also support stricter measures against illegal and non-beverage products, beginning with the imposition of excise taxes on strong alcohol beverages and medicinal tinctures, ultimately moving to a total ban on sales of medicinal tinctures.
Oblast authorities faced a conflict because of the substantial contribution of alcohol industry to oblast tax revenues. In addition, they perceived the scope of any effective policy initiative to be beyond their remit, because the legal framework within which they work is determined largely at the federal level. There was only a partial recognition that they could do more to enforce existing regulations.
All health-sector organizations accepted their responsibility for tackling problem drinking, but saw their role mainly as maintaining adequate treatment services for people with alcohol problems. The highly specialized narcological and psychiatric dispensaries are supported by a network of physician-narcologists and psychiatrists in some policlinics and hospitals, These are seen by the rest of the health sector as natural leaders on alcohol issue. They supported a total ban on production of medicinal tinctures, but saw scope for prescription of ethanol containing medicines under medical supervision. So far they had concentrated on provision of treatment but they did concede that they could play a role in shaping policy by drawing attention to the magnitude of the problem and taking advantage of the popular perception that they were experts.
The education sector, organized at the municipal level, saw health promotion as a high priority, and especially prevention of alcohol abuse among adolescents. It also supported stricter controls on sale of alcohols to underage youth, beginning with increasing the minimum age for sales to 21 years, extending to making sale of alcohol to underage drinkers a criminal offence.
The pharmaceutical sector, and particularly the large pharmaceutical chains, saw their responsibility as complying with the 2006 legislation but, as with the alcohol industry, there were differing views. The large and medium chains expressed concern about their reputation and sought to position themselves in the more affluent sector of the market. They argued that their larger scale of operation posed greater risks, compared to independent pharmacies, should they be found to violate 2006 regulations, which prevent sales of tinctures in bottles larger than 25 ml. This was borne out by our earlier research that found the regulations flouted more often in independent pharmacies.7 There was recognition that independent pharmacists obtained a substantial share of total profits from these tinctures, especially because they found it difficult to compete with the lower wholesale prices of drugs obtained by large chains (most people pay directly for drugs prescribed outside hospital). Unsurprisingly, large pharmaceutical retailers supported restrictions on sales of tinctures, although they did not see it as a high priority. In contrast, while independent pharmacists accepted that there was a problem, they were unenthusiastic about measures that would impact on sales and indicated that they would continue to sell such products ‘under-the-table’ unless there was very rigorous enforcement.
Alcohol retailers, including owners of street kiosks, saw their responsibility as following regulations banning sale of alcohols to underage youth. However, they acknowledged that alcohol revenues accounted for much of their total income.
Industrial employers were interested in broader measures that would reduce problem drinking in the workforce. However, they had a narrow perspective: alcohol consumption at work was no longer tolerated, and was a common reason for dismissal. In contrast, problem drinking outside work hours was generally tolerated and measures to support problem drinkers were weak or non-existent.
Other sectors, such as community, ethnic and religious organizations, supported a wide range of restrictions on alcohol as well as increased rehabilitation and community support services, although these are of unknown effectiveness.
Only two groups could be considered to exert a significant impact on policy. These were some producers and the federal government bodies. Producers of local spirits exerted influence by virtue of their contribution to taxes: in 2007, they contributed 1.7 billion roubles (€47 million) in excise duties, placing the region among top 10 Russian oblasts in terms of alcohol tax recovery. Obviously, opposition to measures that would reduce alcohols consumption was strongest among them. In pursuing their agenda of minimizing excise taxes they stressed the message that adverse health effects of drinking were largely attributable to ‘low-quality’ illegal and bootleg vodka, implying a necessity to ensure a supply of cheap legal spirits. The manufacturers of spirits also strongly opposed any local restrictions, reporting that, in 2007, 64% of their output was sold in the Oblast.
Beer producers were divided. National and transnational beer producers were increasingly influential, using their resources to secure support in oblast and municipal authorities. Strategies included creation of new production facilities and expensive advertising campaigns backed by sophisticated market research beyond the scope of local producers, reduced prices to gain market share and subsidized delivery to retailers. Transnational beer producers also exert influence at the federal level, supporting tax increases on low and medium alcohol products, such as alco-pops and wines, as in 2007 (62%). In contrast, local producers perceived themselves as having little influence on oblast authorities that they viewed as indifferent to their plight. They perceived themselves as a ‘milk cow’ providing substantial revenues but getting little in return. Several local producers had recently ceased trading, while the remainder had scaled back investment in manufacturing capacity. Those that survived had seen a marked decline in sales.
The influence of the federal government lay in its legislative power, illustrated by the enactment of the 2006 legislation. Partly as a consequence of the decentralized nature of government in the Russian Federation, federal ministries were seen as having little influence.15 However, with the establishment of a federal body to regulate the alcohol industry ‘Gosalcocontrol’, the federal government is becoming more influential. Many experts see this as creating greater opportunities for lobbying by the largest producers.
In contrast to the clear opposition by the alcohol industry to policies to reduce drinking, most other stakeholders that might be supportive had so far paid little attention to the issue, or adopted a very narrow perspective.
Rospotrebnadzor, the trading standards organization, was active in targeting contaminated spirits, while ignoring the vast majority of non-beverage alcohols that contain pure ethanol.
Oblast and municipal-level authorities took a very limited view of what could be done. They acknowledged little opportunity to influence federal alcohol policy and did little within their own areas of responsibility, such as their power to restrict hours when alcohol can be sold. Among oblast ministries, the Ministry of Internal Affairs was seen as among the most powerful, but it limited its activities to tackling production and sale of illegally produced alcohols (both home distilled and diverted from industrial production).
The oblast Health Ministry, although often stating the importance of tackling the health consequences of alcohol abuse, had little influence on policy. None of the health-sector organizations was especially influential on broader alcohol policy, reflecting their narrow focus on treatment.
The education sector had been able to implement a few initiatives, such as health-promotion programmes targeting high school students and their families, taking advantage of links with the World Health Organization (WHO) ‘Healthy Cities’ and ‘Healthy schools’ programmes. Twelve of approximately 100 high schools in the oblast capital employed psychologists and ‘social teachers’ who worked with students exhibiting problem behaviour. These students often came from families where one or both parents are problem drinkers. The education authorities sought to create healthy and supportive environments for children that will protect them from the influence of aggressive alcohol and tobacco promotion campaigns. Overall, the educational sector understood the scale and nature of the problem, and was motivated to respond, but felt that it had little influence on alcohol policy beyond its immediate sphere of action.
The pharmaceutical sector was generally indifferent to the problems associated with alcohol, with little to say in policy debates and failing to perceive any opportunities to exert influence.
Alcohol retailers, including those owning small kiosks and outlets, were fragmented and lacked influence, except through informal links with those seeking to tackle illegal sale of beverages to youth and non-beverage alcohols.
Other organizations representing religious and community groups acknowledged little influence on policy.
The findings from this study are represented in an influence map (figure 1), which examines linkages between various stakeholders. This shows central role of the Federal and oblast municipal governments, as well as Rospotrebnadzor, the trading standards organization and transnational beer companies and spirits producers. It shows how government and alcohol industry are linked through a strong set of formal and informal connections. In contrast, many of the organizations that, in a Western context, might be expected to engage in a multi-sectoral response to problem drinking, are somewhat peripheral, disengaged and with few or weak interconnections, either to the more influential stakeholders or to each other.
A number of caveats are necessary to interpret our findings. The study was limited to a single oblast of Russia, so we cannot know whether views elicited would be the same elsewhere. We must also recognize the possibility that interviewees may seek to mislead about their true views. However, the interviews were designed to detect inconsistencies and those interviewed appeared to be willing to speak frankly and their views were entirely consistent with their roles and incentives. This may be because we did not record the interviews on tape. Our pilot work showed this would inhibit discussion. We also described the situation at a single point in time, although stakeholders’ views can change. Finally, we were unable to interview some stakeholders, such as producers and distributors of non-beverage and illegal alcohols, and we did not interview stakeholders operating at the federal level.
Our findings are consistent with theory underpinning stakeholder analysis. There were a number of policy entrepreneurs (in this case producers) who were willing to invest their efforts in bringing about their desired policy future.12 We also identified the existence of both administrative networks (linking agencies engaged with the issue) and interest group networks (such as those involving producers and government as, respectively, generators and recipients of revenues).16
There were two striking findings. The first was that many organizations that we might expect to play a role in alcohol policy were almost entirely disengaged: while almost everyone recognized that there was a problem (even if they disagreed about its nature) they believed that they could do nothing about it. We did, however, elicit considerable interest when explaining the issue to interviewees and describing policies adopted elsewhere. The second was that those who might favour restrictions on alcohol were highly fragmented. There was no evidence of a multi-sectoral coalition for health. However, this fragmentation was also seen among those opposed to effective action.
As expected, not everyone was in favour of reduced consumption. Producers of beer and spirits as well as small retailers all seek to at least maintain consumption of their products. Some, especially the smaller ones, have little influence, but the market is changing with entry by larger companies with expertise in marketing and distribution. Their messages are often sophisticated, such as the apparent promotion of responsible drinking by international beer companies, even though the messages are ambiguous, with many people interpreting them as encouraging both drinking and positive images of producer.17,18 These techniques, coupled with massive investment in production and distribution facilities, have contributed to a dramatic increase in beer consumption in Russia, from 15 l per capita in 1996 to more than 60 l in 2007. Yet, official production of spirits remains undiminished, exceeding levels in 1990 and comprising 70% of all legally produced alcohol. Thus, increased beer consumption seems to be supplementing rather than substituting for spirits consumption.
We observed a widespread view that little can be done at the oblast level. Yet, other regions have refuted this. Some have restricted the times at which alcoholic beverages can be sold (e.g. Pskov and Chelyabinsk), while Belgorod has banned the sale of alcohol containing medicinal tinctures without a prescription. Other non-legislative measures observed include information campaigns, non-medicalized counselling and treatment services as well as enforcement of drink-driving restrictions.
Although ministries and regulatory agencies recognize that there is a problem, they are either conflicted, because of the revenue provided by the alcohol industry, or feel that it is not their responsibility. In part, their unwillingness to assume responsibility reflects a belief that it is up to federal bodies to act. Paradoxically, this may have been encouraged by the federal authorities’ restriction of production and sale of surrogates. A second factor is the lack of inter-sectoral working to promote health. This leaves the increasingly vocal alcohol producers in a strong position to block any potential restrictions on their activities.
These findings do, however, provide some grounds for optimism. First, there is almost complete consensus that robust action is required to tackle the problem of non-beverage alcohols, except among independent pharmacists. Second, there are organizations that share concerns about the scale of alcohol-related problems facing Russian society. Although most feel it is not their business to become involved and few know what might be effective, they could be mobilized to create a coalition that would work across sectors.
There are some things that could be done at once. The debate about loss of revenues was clearly being conducted without awareness of the growing evidence, indicating that alcohol has a substantial economic cost through its impact on the health service, lost productivity and law enforcement, although this evidence has been assembled for Russia.19,20 Second, information on scale of the problem, whereby hazardous drinking now accounts for almost 50% of deaths among working-age men in Russia, as well as the lessons learnt from policy innovations in other oblasts, should be provided to those organizations that have expressed concern, but are unsure what to do.
Following the completion of these interviews, certain federal policy measures were enacted. In May 2009, the Public Chamber of the Russian Federation proposed a comprehensive range of measures designed to reduce harmful effects of alcohol.21 The proposed measures address all sources of alcohol and draw on evidence-based policies used elsewhere. Whether these recommendations will be acted upon remains to be seen. However, our findings highlight the challenges that any federal initiative will have to overcome if it is to be implemented and reinforced effectively at the local level.
This study was funded by the Wellcome Trust.
Conflicts of interest: None declared.