1. Introduction

The use of tobacco products is among the leading cause of preventable morbidity and mortality because of well-known risks associated with cardiovascular disease, cancers, chronic respiratory pathologies, among other noncommunicable diseases.1,2 Eight million deaths a year can be linked to the consumption of tobacco products. Therefore, there remains an important need for heightened public health efforts among countries experiencing persistent and rising threats associated with tobacco products.2 Studies conducted within the boundaries of Saudi Arabia indicate that an imminent trend of epidemic tobacco consumption prevails within society. The prevalence of cigarette smoking was found to exist at 12.2% among adults in 2013,3 but more recent estimates indicate that 15.6% of respondents demonstrated smoked tobacco consumption and 8.6% showed smokeless consumption with stark disparities related to gender and socio-economic factors.4 For adults, adult prevalence was recorded at 19.8% in 2019 under the Global Adult Tobacco Survey.5 Compared among younger age groups among youth under 15 years old, adolescents demonstrated 8.8% prevalence of tobacco consumption under the 2022 Global Youth Tobacco Survey, which remained significantly associated with ever-being exposed to SSM and MM.6 These findings indicate increasing tobacco use and associated noncommunicable disease burden in the region.

Over the years, Saudi Arabia has gradually expanded tobacco control policy measures within broader health system reforms to include other measures like smoke-free areas, advertising bans, taxation increase, and increasing support services for quitting efforts7–10 In regions with more stringent advertising bans, cigarette cartons themselves become “mobile billboards,” which promote brand identity and assist with product differentiation.11,12 There is evidence that flavorings and other visual features target spots close to locations of educational facilities.13–16

Standard or plain packaging reduces or eliminates branding and promotion-based features; hence, pictorial health warnings become more prominent. Some research studies using Australian, UK, Singaporean, Uruguayan, Turkish, Colombian, and Filipino samples report findings showing reductions in perceptions of package appeal and cognition-based attempts to avoid products linked to perceptions of risk.11,12,17–27 Packages with no branding were introduced in Saudi Arabia in 2019 under SFDA’s technical regulation SFDA.FD 60.1,28 This was relatively fast and drew considerable public discussion with emphasis on responses and concerns raised on different social media platforms with regard to differences in taste.29 SFDA.FD 60 standardizes tobacco packaging across cigarettes, cigars, waterpipe tobacco, and loose tobacco. The regulation mandates uniform pack color, removal of branding elements and logos, standardized typography, and prominent graphic health warnings with specified size and placement.

The study proposes three assumptions. Firstly, it is evident from the case study of Saudi Arabia that the outcome of plain packaging is dependent on dispute resolution processes in this digital era and trust building.29,30 Secondly, implementation can only happen if it considers the package environment with regard to products like flavoring cards, insert cards, RYO products, smokeless packaging types, devices for vaping products, and brands on products used after consumption.15,16,23,31–34 Thirdly, plain packaging can only work as an enabling structural element whose efficiency depends upon structural integration with taxation systems, improved health messages, strict processes of implementation, and easily accessible facilities related to abstinence.31,35,36 By applying the Health Policy Triangle,37,38 this paper considers the experience with regard to the implementation of plain packaging that was introduced under WHO’s Framework Convention on Tobacco Control in the Eastern Mediterranean Region in terms of evidence-based knowledge and commercial influences on health.39

2. Conceptual Framework: Health Policy Triangle and Commercial Determinants

The Health Policy Triangle places health policy at the intersection of context, content, actors, and process.38 It has been used comprehensively to examine various processes associated with designs of health policy and how these designs emerge and are interpreted when they encounter processes related to their implementation.37

Regarding tobacco control measures, the attention becomes especially focused on health promotion targeting (HPT) because packaging “becomes an important commercial driver because of its ability to drive status messages; create false perceptions about low-tar yields or naturals; establish brand identity with the capability to migrate into different forms of market promotion based on reductions or bans on surface areas”.11,12,16,33,34 Industry adjustment refers to “flavored products; RYO products; non-compliant SLLS packaging; inserts/onsert cards (materials attached to package exterior surface); color schemes indicative of preferred products; cigarette filters; and engagement with informal markets”15,23,32

For purposes of this analysis, the Health Policy Triangle model (HPT) will serve as an analytical instrument to investigate the following: (1) how factors of an epidemiologic or political nature contributed to healthcare policy formulation within Saudi Arabian government; (2) how SFDA.FD 60 compares to or deviates from best practice; (3) how different actors: regulators, industry interests, and activists-publics utilizing digital communications tools; disputed healthcare policy; and (4) how factors related to communications failure and initial outcomes contributed to implementation processes.29,30 The intersection of applying Health Policy Triangle with knowledge related to commercial determinants shows market shift occurring within the landscape of packs and how digital communications tools transform actor constitution to significantly expand beyond original level of analysis concerns.

3. Methods

In this study, a policy analysis using only secondary data will be applied. The role of this analysis would not be to draw any conclusion or inference related to cause and effect but would emphasize how using the Health Policy Triangle and commercial determinants could assist in analyzing and interpreting Saudi’s plain packaging policy among other evidence provided internationally.

3.1. Source selection

A narrative review was performed utilizing PubMed and Scopus, supported by relevant grey literature from reputable sources including the World Health Organization (WHO) and the Saudi Food and Drug Authority (SFDA). Investigations were conducted for papers published from 2013 to 2025 utilizing combinations of terms such as “plain packaging,” “tobacco,” “smoking,” “standardized packaging,” “Saudi Arabia,” “waterpipe,” and “smokeless tobacco.” Further evidence was discovered via manual examination of reference lists from significant WHO and SFDA studies. Forty-six research and policy documents were included due to their importance to tobacco-control measures, policy implementation, consumer perceptions, and commercial determinants of health.

Articles were selected if they met at least one of the following criteria: (1) if they were concerned with primary or secondary empirical research findings on cigarette consumption or plain packaging regulations related to countries within Saudi Arabia; (2) if they were concerned with global research findings or experimentation or perceptions related to plain or standardized packaging; (3) if they were concerned with commercial factors associated with health outcomes related to packaging regulations; or (4) if they were concerned with conceptual research related to health policy analysis or associated regulations related to packaging. Seven broad categories of material were retained:

  1. Saudi regulatory and policy documents related to packaging and labelling, particularly SFDA.FD 60 and subsequent guidance on tobacco product packaging.28,40

  2. Saudi-specific empirical and review studies addressing the rationale for plain packaging, implementation experiences, public perceptions, and complementary dissuasive measures such as cigarette-stick warnings.7–10,29,30,41–43

  3. International systematic reviews, narrative syntheses, and bibliometric analyses on plain packaging and related measures, including studies of perceptions, pack appeal, warning salience, misperceptions about “low-tar” products, and youth uptake.11–13,17,18,28

  4. Impact evaluations, experiments, and perception studies from countries that have implemented, considered, or are preparing for plain packaging, including Australia, England, Canada, Ireland, Singapore, Uruguay, Turkey, Colombia, Ghana, and the Philippines.15,16,19–27,35,36

  5. Studies on illicit and non-compliant products, especially smokeless tobacco packaging and illicit combustible products in South Asia and Australia, which illustrate how packaging regulations can be undermined in practice.32,33,36

  6. Modelling studies and policy commentary on the health impact of plain packaging and its integration into broader tobacco control strategies, with particular emphasis on Australia and Argentina.31,44

  7. Global burden and policy reports, primarily WHO publications and related global analyses on tobacco use, noncommunicable disease (NCD) prevention, and the MPOWER package.1,2

The focus was on studies which underwent peer reviews and official reports. The inclusion of commentaries or grey literature was informed if contributions were analytical with the objective of offering viewpoints not offered by other types of documents or research methodologies. Rather than basing quality on an appraisal instrument, the study used triangulation on document types and research designs.

3.2. Analytical approach

The data that was extracted was systematically organized using the Health Policy Triangle model conceptual tool (context, content, actors, process) designed by Walt and Gilson.37,38 For every source paper, there was corresponding data assigned into at least one category of Health Policy Triangle areas.

  • Context: epidemiological burden of tobacco use, economic and political setting, broader governance reforms, and international normative environment, including WHO Framework Convention on Tobacco Control (FCTC) guidance and experiences of early adopter countries.

  • Content: scope and design of SFDA.FD 60, including product coverage, pack specifications, and integration with tax and other MPOWER measures, as well as attention to elements of the wider “pack environment” such as inserts, filters, dissuasive sticks, and branded litter.

  • Actors: roles and strategies of domestic government agencies, health professionals, tobacco companies, advocacy groups, the public and media (particularly social media), and international organizations.

  • Process: sequences of policy formulation, adoption, implementation, contestation, enforcement, and early outcomes, including public reactions, narratives about taste and authenticity, and concerns about illicit or informal markets.

In these and other contexts, an iterative process was used for analysis. Firstly, descriptive profiles were built for the case of Saudi Arabia based on compilation of regulatory texts, empirical studies carried out in Saudi Arabia, and World Health Organization reports.1,2,28–30,40–42 Thirdly, assessment studies from other countries were used comparatively to spot areas of similarity and differences between Saudi Arabia and other countries with regard to context factors, actor configurations, and contents.11,12,19,22,23,31,35 Lastly, specific emphasis was given to effects on environments within public packs, using literature associated with commercial determinants and tobacco control efforts, especially related to industry adaptation techniques (flavorings, roll-your-own products, non-compliant packaging of smokeless tobacco products, insert and onserts, branded filters, post-consumption litter).15,16,32–34,44

The study applied HPT structured synthesis, not for investigating causal attribution, but for researching how, or in what ways, evidence-based technical robust regulatory content co-conditioned with commercial strategic evolution throughout or because of the implementation of plain packaging in Saudi Arabia; how, or in what ways, different actors starting with an actively engaged public, contested and co-defined policy; how, or in what ways, these processes co-condition eventual impact.

4. Results: Health Policy Triangle Analysis

4.1. Context

The case study on Saudi Arabia’s experience with plain packaging was situated within the context of mature, gendered, and socially patterned tobacco epidemic.3–6 These patterns underlie rising noncommunicable disease morbidity and form part of an impetus for policy efforts to reduce product appeal and enhance risk communication.

There exist precedents internationally on which of these expectations can be grounded. These countries – Australia, United Kingdom of Great Britain and Ireland, Ireland, Canada, Singapore, Uruguay, Turkey, and Colombia – have established robust evidence on packs with lower appeal, more prominent warnings, and perceptions.11,17–23 A bibliographic analysis reveals that Australia and United Kingdom lead the production of research on this subject with low production among countries of the Eastern Mediterranean.39 Commercial drivers also play important roles, as shown from studies in countries like Uruguay, Argentina, and India show adaptability within the industry with different flavorings, visual packaging, and establishment of novel product categories.15,16,33 Studies emerging from South Asia show widespread non-compliance for smoke-free packaging and a substantial level of black market activity.32 These trends correlate well with concerns manifested at the level of countries like Saudi Arabia, where shisha products, roll-your-own products, and emerging e-vapor products show increasing usage.

4.2. Content

SFDA.FD 60 promotes the unity of package designs for cigarette, cigar, waterpipe, and loose tobacco products.28,40 The regulation sets strict requirements for the similarity of basic colors, typographic designs, the absence of brand logos, and the specific positioning and size of graphic health warnings.1 These mandates comply with World Health Organization guidance and the standardized packaging regulations established in Australia.1,17,42

The regulation addresses factors proven to drive product appeal, such as brand names, color-based cues, and descriptive terms linked with “smoothness” or “low tar,” which are associated with the misperception of risk.11,12,45 Evidence from Canada, Ireland, Turkey, and Singapore demonstrates that appeal can be diminished and avoidance responses increased through standardized packaging combined with varied warning messages.19–22 However, the current regulatory environment in Saudi Arabia lacks specific guidance regarding insert and onsert content, filter types, stick-level warnings, and the packaging of snuff or vaping products. Cross-country research reveals that these unregulated components often serve as primary channels for branding reintroduction.33,34 Furthermore, experience in Uruguay and Argentina demonstrates that industry response to plain packaging often involves a shift toward product development in flavored varieties and roll-your-own (RYO) tobacco products.15,16

4.3. Actors

The delivery of these measures was facilitated by SFDA and the Ministry of Health, taking advantage of their regulatory power and implementing MPOWER strategies.8,9,42,43 The tobacco sector showed lower public engagement activities but still had an impact on public perceptions of products with diversification communications and implicit messages about authenticity and product quality; these were consistent with global industry practice.7,12,15,16,32,36 Public audiences greatly contributed to this study. There was public discussion on Twitter about flavor diversification and product copying shortly after the product was introduced; therefore, there was need for communications concerning these issues.29 It would seem that smoker perceptions of government organization trustworthiness affect compliance with behavioral change.30 There were contributions with regard to product quality at launch, trial design, and smoker support for these audiences.41–43

4.4. Process and Early Outcomes

SFDA.FD 60 was launched in 2018 and commenced in 2019 after the transition phase.1,28,42 Although implementing these regulations at a fast pace helped achieve conformity with best practices globally, it hindered engagement with smoker and retailer audiences before implementation. The initial public response brought into focus a lack of proactive communications.29 Notwithstanding this outcome, initial results show that plain packaging with accompanying price increases which have been associated with improved quit intentions.41 International reviews with Ireland, Canada, Ghana, Turkey, Singapore, and Colombia show parallel shifts in perceptions and avoidance.19–24,26 It is expected that the long-term behavioral outcomes will only be moderate unless sustained with taxation measures, upgraded warnings, quit services, and regulations on illegal markets; similarly observed in England, Australia, and South Korea.35,36,45

5. Discussion

By applying Health Policy Triangle analysis to investigate the implementation of plain packaging in the Saudi Arabian experience, three interrelated outcomes can be determined which extend beyond traditional case study research parameters. These outcomes can be encapsulated as follows: (1) trust and contestation within an institutional field remains supreme under digital age realities; (2) “pack environment” has important commercial forces bearing upon health outcomes; and (3) plain packaging only has structural but facilitating features provided it becomes integral to an exhaustive scheme of cigarette control strategy.

5.1. Digital-era regulatory trust is a decisive mediator of policy impact

Although SFDA.FD 60 can now arguably be said to conform to best practice and has exemplary design,17,28,40 it would seem that the value of policy credibility can relate to more than just matters of regulatory detail, at least so far as what can be learned about this subject from experience in Saudi Arabia would suggest. Undoubtedly public reaction to SFDA’s efforts at implementation, meaning how easily reports of differences of taste and authenticity were shared, which were almost instantaneously public, would suggest that there was not alignment between technical specifics and public perceptions of those specifics.29 This dynamic points to a weakness inherent in traditional HPT because it predated public engagement with social media. Talking specifically about the case of Saudi Arabia, “actors” and “process” cannot satisfactorily be understood apart from the role of digital media networks as spaces for debate and power boosters of institutional mistrust. The growing evidence for a link between perceived regulatory credibility and preparedness to adapt behavior was found to underscore the behavioral significance of trustworthiness of implementing bodies.30

International research evidence from Ireland, Canada, Ghana, and Philippines demonstrated that community support for plain packaging can grow if communication with consumers is clear, prospective, and youth protection/warning label prominence-focused.19,20,24,26,27 These studies suggest that within electronically facilitated interactions, while stronger regulatory systems can assure the efficacy of plain packaging measures, state abilities to secure and sustain communication spaces early on can significantly matter too. Thus, the case of the implementation of this policy action in Saudi Arabia serves to offer an interpretive perspective: that plain packaging can thus be viewed as an instrument of epistemic trust and that Health Policy Theory (HPT) requires an explicit level of adaptation to accommodate the fact of contested publics.

5.2. The true regulatory battleground is the wider “pack environment,” not the external pack alone

The other significant outcome concerns the limitation posed when concentrating only on the outer wrapping of cigarette packs. While it can indeed be perceived that Saudi Arabia has relatively extensive coverage when it comes to cigarettes, cigars, waterpipe tobacco products, and loose tobacco products; at the same time, industry response depends precisely on those areas which fall beyond those areas regulated under so-called “standardized packaging”.28,40 It was determined that experience demonstrates evidence of advertising migration into areas such as product flavors, RYO product sizes/counts, product and package-colored cues, insert/onsert cards, filter brand branding, innovative product component promotion, and even table-tipping litter (i.e. branded tobacco-related litter).15,16,32–34

Studies focusing on South Asia show that non-compliant smokeless packaging types and large-scale unregulated markets can significantly limit regulatory efforts.32 Roll-your-own (RYO) tobacco products and flavor varieties gained popularity in Uruguay and Argentina as differentiating features after factory-made packs were standardized.15,16 Branded tobacco litter successfully expanded promotions into public areas despite the implementation of plain packaging regulations in India.33 Furthermore, studies using discrete choice experiments in Colombia indicate that while plain packaging reduces consumers’ willingness to pay for legal products, featuring messages on cigarette sticks is relatively less important, and unauthorized substitutes still appeal to cost-conscious consumers.23

The Saudi Arabian case is at the cutting edge of these regulatory concerns. While the basic model of regulation remains strong, detailed regulations with regard to inserts, onserts, filters, dissuasive packaging designs, e-vaping devices, and post-use branding rules are still relatively weak. The message is clear: the efficacy of plain packaging would be undermined if branding were able to re-emerge somewhere else in the product universe. It therefore follows that the Saudi case offers an important lesson: that in modern markets for tobacco products or other commodities, analysis at product (or package) level alone will not capture well how markets can exert influences on public health policy. The dimensions of “content” and “actors,” under Health Policy Theory (HPT), therefore need to be reframed to show how commercial factors permeate product features, grey markets, and public spaces.

5.3. Plain packaging is an enabling structural intervention, not a standalone behavior-change measure

The third finding relates to the specific position of plain packaging within more comprehensive tobacco control policy contexts. Cross-national studies show that plain packaging works to reduce package appeal, increase negative affective responses, increase prominence of warnings, and influence perceptions; but often leads to only small immediate shifts in behavior when other factors are not addressed.19–22,35 Outcomes based on Australian and English studies suggest that consumption pattern shifts occur over time and result when mildly related taxation schemes and quit programs serve as intermediaries.35,36 Outcomes based on studies in South Korea suggest that misperceptions occur when other messages related to tar yields are not regulated.45 Modeling done in Argentina shows that it would only take small reductions in prevalence to achieve large benefits for cardiovascular outcomes.31 It fits well with how plain packaging can be thought of rather more broadly as an infrastructural component; it influences the environment within which decisions occur, but it cannot achieve maximum effect on its own with other factors like taxes, bans on flavor and descriptives, and access to quitting resources.

Evidence from Saudi Arabia’s early years conforms to this trend. A combination of taxation, pricing effects, and plain packaging has been perceived to encourage men in Riyadh to quit smoking.41 Yet knowledge and utilization of quit facilities seem low, while perceptions of product quality, which can be fed by public perceptions on various social media platforms,9,29,43 affect behavioral outcomes. These observations seem to point to the limited efficacy of plain packaging in Saudi Arabia if enhanced cessation facilities and risk communication efforts are not simultaneously addressed.

This adds to global knowledge with regard to how standardized packaging operates with other complex factors of taxation, market structure, institutional credibility, and new nicotine products within an upper-middle-income early adopter state. Throughout these topics, there is a more general lesson provided: There is a need for technical alignment with global standards but it alone may not sufficient for ensuring attainment of such policy objectives. By virtue of limiting either the symbolic or commercial role of the package, tobacco control policy measures necessarily entail recognition of these contested digital spaces and commercial ecosystems because technical alignment with global standards alone cannot necessarily lead to attainment of policy objectives with these types of measures. Cultural knowledge with regard to these matters can now clarify that technical measures like standardized packaging need to occur with other measures related to limiting these commercial factors to achieve maximum attainment of policy objectives.

5.4. Policy Implications

There are several implications arising for countries like Saudi Arabia that have introduced or contemplate introducing plain packaging. First, while countries like Saudi Arabia can benefit from expert knowledge and experience prior to implementing plain packaging regulations, it draws attention to the need for proactive engagement with communications on new technologies like social media.29 Before or while implementing plain packaging measures, governments need to adopt appropriate and robust communications with clear explanations on why they introduce standardized packaging and to dispel misperceptions or doubt with regard to their credibility.30

Second, the evaluation of standardized packaging should routinely connect it with quit assistance rather than examining it as an isolated measure. There is evidence that plain packaging has been associated with avoidance, negative affective responses, and heightened quit intentions found in studies carried out in Saudi Arabia and other countries.19–21,41 These outcomes can more feasibly lead to long-term behavioral shifts if quitline details on cigarette packaging and novel warnings point those interested in quitting towards available quit assistance programs.9,22,43

Third, policymakers must address the complete environment of packs instead of just limiting themselves to factory-made cigarette packs’ exterior surfaces only. Pack inserts, filters, stick-level messages, RYO (roll-your-own) packs, smokeless products, and e-vapor products can function as potential residual promotion spaces for re-establishing brand identity and appeal.15,16,32–34 There exist precedents throughout the globe that can benefit policy expansion related to Australia’s ambition to keep at the lead in tobacco control efforts and the developments taking place within Philippines.24,25,44

Lastly, improving surveillance and enforcement efforts would significantly help to ensure that erosion of regulations does not occur. Evidence of lack of compliance with regulations related to smokeless tobacco products’ packaging and with unauthorized or unstructured markets in South Asia and other areas shows that package audits and surveillance with significant punitive measures when there is lack of compliance with these regulations would be necessary.14,32,36 Models indicate that moderate declines in smoker prevalence could lead to significant population-level health gains, especially with regard to CVD outcomes.31 Considering these factors, it appears that plain packaging would only lead to reductions if comprehensive measures that would combine communications and quit services with regulations related to packaging conditions, were implemented together.46

5.5. Limitations

It must be stated that this analysis relies only on secondary data and cannot establish causal linkages between behavioral shifts and plain packaging designs. Available empirical studies within the Saudi environment are relatively restricted and narrow.30,41 Most studies internationally were conducted among countries with different market and capacity characteristics.19–22,35 The HPT model cannot comprehensively establish informal politics or industry-level influences behind the scenes. By considering industry and global evidence studies,11,23,34 there exists adequate interplay to draw thoroughly upon analysis related to the case study of Saudi Arabia.

6. Conclusion

The experience of implementing plain packaging in Saudi Arabia marks an important step within the region towards enhancing tobacco control efforts; however, this experience cannot be comprehended through an examination of regulations only. By using the Health Policy Triangle analysis tool, SFDA.FD 60 can be regarded as fit and conforming to global standards; however, there exist three factors that define how a plain packaging policy operates within modern cigarette markets. First, the reception of the policy showed just how important trust and contestation under digitization were. Public discourses of quality and authenticity were easily disseminated via social media platforms to transform an important qualitative aspect of regulations into perceived quality failure. In other words, ordinary packaging is not only about efficacy but can also determine how regulations can or cannot be trusted under digitization. Second, there’s emphasis on the importance of the overall package environment. While regulations applied by Saudi are for more than just tobacco products alone, market migration could occur into flavor products, roll-your-choice products, inserts, filters, smokeless tobacco products with flavoring or accessories, e-vapor products with flavoring or accessories, and consumption branding products. Unless these areas experience equal regulations too, then market migration due to package brand appeal can still occur. Third, the case of Saudi Arabia supports the idea that plain packaging acts as an enabling structural intervention with contingent behavioral effects depending on other policy considerations. Evidence gained in countries like Saudi Arabia has demonstrated that plain packaging can shift perceptions and aid quit attempts but ultimately depends on factors like taxation rates, warning labels, illegal trade activity, and quit aids. These factors need to be holistically incorporated, especially when countries face variances in nicotine markets and public debate occurs at rapid rates. These lessons situate the experience of Saudi Arabia as an informative example for early adopters among other countries with similar economic profiles considering implementing plain packaging themselves. It would appear that plain packaging could offer the greatest benefits when viewed not simply as a single tweak to existing regulations but rather within an overall policy vision to moderate commercial influences on health outcomes and with an eye to more directly engaging civil society’s cooperation rather than simply relying on government positions to bolster popular trust of health regulations.

Conflict of Interest / Competing Interests

The authors declare no competing or conflicting interests.

Acknowledgments

None.

Data Availability

No datasets were generated.

This study uses only publicly available secondary data (policy documents, published studies, and institutional reports) and does not involve human participants; therefore, ethical approval and informed consent were not required. Any references to public discourse are analyzed at an aggregate level without identifying individuals. The study adheres to standard principles of research integrity and proper source attribution.

AI Tool Use Disclosure

AI tool: ChatGPT. Provider: OpenAI. Version: GPT-5, Nov. 2025. Purpose: Language editing. Verification: The authors reviewed and verified all output.

Preprint Disclosure

This article has not appeared as a preprint anywhere.

Third-Party Material Permissions

No third-party material requiring permission has been used.

Funding Statement

The authors received no financial support for the research, authorship, and/or publication of this article.

Reporting Guidelines Statement

This study is a narrative policy analysis based on secondary data and does not follow a formal reporting guideline. However, the reporting approach was informed by established practices for narrative reviews and policy analyses, with attention to transparency in source selection and analytical framework (Health Policy Triangle).