BMJ Global Health has published a series of scientific papers on health taxes in the October 2023 issue (October 2023 – Volume 8 – Suppl 8) simply called “WHO: Health Taxes”.
The BMJ Global Health is an open access journal publishing high-quality peer-reviewed content relevant to anyone involved in global health or interested in global health matters, such as policy makers, funders, researchers, clinicians, and frontline healthcare workers. Since 2002, Dr Seye Abimbola, PhD University of Sydney in Sydney, Australia is the editor-in-chief.
BMJ Global Health publishes high-quality, original contributions where all submitted articles are peer reviewed to assure the highest quality. It has an impact factor Impact Factor of 8.1 and a Citescore of 9.1.
The “WHO: Health Taxes” Issues
In the October 2023 – Volume 8 – Supplement 8 “WHO: Health Taxes” issue the BMJ Global has released a total of 15 peer-reviewed scientific papers on the subject of health taxes. These papers cover countries and regions around the world and different types of health taxes.
Countries and regions covered:
- Philippines,
- Vanuatu,
- Ethiopia,
- Mexico,
- Egypt,
- Indonesia,
- Nepal,
- Peru,
- East and Southern Africa,
- Ghana, and
- the Pacific region.
Health taxes covered:
- Food tax,
- Sugar-sweetened beverage tax,
- Tobacco excise tax,
- Sugar-sweetened beverage tax,
- Excise tax on waterpipe tobacco,
- Tobacco, alcohol, and SSBs taxes,
- Perception of alcohol and tobacco taxes,
- Health taxes,
- Tax to meet the health financing gap,
- Food-related health taxes, and
- Food pricing policies.
The series of scientific papers also deals with reviewing the evidence and dispelling the myths around alcohol tobacco, and SSBs taxes in general, and the health sector and fiscal policies of fossil fuels.
There is no paper that explores a stand-along country case of alcohol taxation, even though multiple countries have successfully implemented evidence-based, public health oriented alcohol excise taxation, such as Thailand, Philippines, Botswana, or Lithuania.
In a message Robert Marten, PhD, the Unit Head at the Alliance for Health Policy and Systems Research of World Health Organization (WHO) explained:
We would have welcomed a paper on alcohol, but didn’t receive one from our open call for papers.
Robert Marten, Unit Head, Alliance for Health Policy and Systems Research, WHO
Dr Marten and the Alliance for Health Policy and Systems Research collaborated with the BMJ Global Health on supplement on health taxes.
Movendi International has summarized key findings and messages of the papers that explore alcohol taxes.
Taxation of tobacco, alcohol, and sugar-sweetened beverages: reviewing the evidence and dispelling the myths
The article reviews the large body of evidence on how taxation affects the consumption of tobacco, alcohol, and sugar-sweetened beverages (SSB).
The paper finds that there is abundant evidence that demand for tobacco, alcohol, and SSB is price-responsive and that tax changes are quickly passed on to consumers.
Health taxes can be highly effective in changing consumption and reducing the burden of diseases linked to these products.
Tobacco, alcohol, and SSB industries oppose taxation on similar grounds, mostly by claiming regressivity of taxes since regressive taxes take a larger percentage of income from low income earners than from middle and high income earners. These health harmful industries also oppose health taxes by claiming these taxes have negative effects on employment and economic activity. And thirdly Big Alcohol Big Tobacco, and Big Soda also oppose these taxes by claiming taxation effects illicit trade.
Contrary to industry arguments, evidence shows that taxation may have short-term negative financial consequences for low-income households. However, medium and long-term financial benefits from reduced healthcare costs, better health, and welfare largely compensate for such consequences.
In addition, taxation does not negatively affect aggregate economic activity or employment, as consumers switch demand to other products that generate employment and may compensate for any employment loss in taxed sectors.
Evidence also shows the revenues generated are generally spent on labour-intensive services. In the case of illicit trade in tobacco, evidence shows that illicit trade has not increased globally (rather the opposite) despite increases in tobacco taxes. Profit-maximising smugglers increase illicit cigarette prices along with the increases in licit cigarette prices. This implies that even when increased taxes divert some demand to the illicit market, they push prices up in the illicit market, discouraging consumption.
Key findings
- Health taxes on tobacco, alcohol, and SSBs are effective economic instruments to change people’s behaviour and reduce the consumption of unhealthy products.
- The article summarises and critically discusses the large body of evidence regarding the effect of taxes on reducing the consumption of tobacco, alcohol, and SSB.
- The article also provides consolidated evidence regarding the lack of economic substance behind common claims that industries use to oppose these taxes (eg, illicit trade, negative effects on employment, regressivity).
- Evidence provided in this article can be used to design and implement health taxes more effectively.
Recovering lost tax to meet the health financing gap for universal public sector health systems in East and Southern Africa
Addressing a total annual tax loss of US$34 billion from these three sources alone would almost completely finance the ESA region’s US$36 billion financing gap for a comprehensive public sector health system.
The COVID-19 pandemic’s exposure of the need for investment in public sector services suggests an opportunity for an alliance between health and finance sectors to ensure progressive taxation as the core funding for an equitable, universal health system.
This implies costing the health funding demands and gap in ESA countries; strengthening domestic tax capacity, expanding wealth taxes, curbing illicit outflows and providing health evidence to ongoing African diplomacy for a fairer global tax system.
Key findings
What is already known
- While direct taxation is documented to be the most progressive form of domestic resource mobilisation for universal health coverage, and comprehensive primary healthcare and a public sector health system to be critical for equity, East and Southern African (ESA) countries have faced challenges in meeting domestic and international commitments to adequate public financing for this and in overcoming catastrophic health spending.
What this study adds
- Comparing three areas of tax losses alone with shortfalls in public sector health financing in the ESA region, addressing a total annual tax loss of US$34 billion would come close to funding the US$36.8 billion shortfall in financing comprehensive public sector health systems in ESA countries.
- Addressing individual areas of tax loss from shortfalls on tax capacities, illicit flows due to commercial practices and unfair global tax rules could fund shortfalls in key public sector health services for universal health coverage and pandemic preparedness.
How this study might affect research, practice, or policy
- Given the scale of the financing gap, beyond smaller pools of innovative financing currently being explored, the findings point to follow-up research and policy engagement to strengthen progressive taxation for public sector health system within the ESA region by addressing the identified areas of tax losses through building domestic capacity within revenue authorities, expanding wealth and other progressive taxes as substantial sources of revenue, blocking illicit financial flows and avoiding tax competition between ESA countries.
- Globally, the adoption of the December 2022 UN Resolution on International Tax Cooperation presents an opportunity to add health evidence to ongoing African diplomacy for a fairer global tax system, to meet public revenue from progressive taxation as the core source of funds for an equitable, universal health system and for pandemic and emergency preparedness in the region.
Political and socioeconomic factors that shaped health taxes implementation in Peru
Peruvian stakeholders against health taxes demonstrated a strong capacity to convey their messages to the media and high-level policy-makers.
Despite these efforts, attempts to interfere with health taxes were unsuccessful in 2016 and 2018 and failed to overcome state institutions, particularly the MoEF. Strong institutions and individual decision-makers in Peru also contributed to the successful implementation of health taxes in Peru in 2016 and 2018.
Key findings
What is already known on this topic
- There is extensive literature worldwide on the political processes that affect the implementation of public health policies, particularly health taxes. Areas such as the effectiveness of implementation, the stakeholders’ participation and industry interference have been more widely addressed by studies.
- In the case of Peru, the implementation of health taxes has been more focused on tobacco than other damaging products. Nevertheless, since sugar-sweetened beverages tax adjustments in 2018 more literature regarding these products has started to be produced.
What this study adds
- This is the first time that health taxes in Peru have been analysed using a political lens, which comprehends the sociopolitical factors that led to the implementation of health taxes policies.
- This study used a framing analysis to understand the arguments of both stakeholders in favour and against health taxes and identify the main stakeholders stating these positions, which had not been studied before in Peru.
How this study might affect research, practice, or policy
- This study offers important insights which can demonstrate and illuminate how political processes affect the implementation of public policies in countries such as Peru.
- The results from our study, which focused on the successful adoption of health taxes, may inform other countries currently discussing similar public policies.
- Gathering public health and economic-related evidence about the impact of health taxes is an excellent way to confront narratives and arguments against these taxes.
How Movendi International supported the alcohol tax in Peru and promotes alcohol taxation in the Americas
In 2019, a policy brief on alcohol policy by the Pan American Health Organization found taxation to be the most effective in reducing alcohol consumption. The report highlights alcohol is a psychoactive substance which caused 379,000 deaths (5.4% of all deaths) in the Americas in 2016 and where alcohol taxation can help substantially reduce morbidity and mortality due to alcohol.
According to the Policy Brief: Alcohol Taxation and Pricing Policies in the Region of the Americas, alcohol taxation was found to save 22 international dollars per Disability Adjusted Life Year (DALY) in low and lower-middle income countries. The saving was 41 international dollars per DALY for middle and high income countries.
In May 2018, the government of Peru introduced new taxes to address harms caused by alcohol, tobacco and sugar-sweetened beverages. Movendi International supported this effort and welcomed these new measures. International President Kristina Sperkova commended the Peruvian government for their leadership to protect the health and wellbeing of their people.
Alcohol taxation is a triple-win measure as it reduces alcohol consumption, eases the burden of alcohol harm, and helps raise domestic resources for health promotion and sustainable development,” said Kristina Sperkova, International President of Movendi International.
On behalf of the members of Movendi International, I congratulate the government of Peru, for putting the wellbeing of their people and the welfare of society first. These health promotion taxes will reap major benefits across the Sustainable Developments Goals.”
Kristina Sperkova, International President, Movendi International
Evidence shows that alcohol adversely affects the Sustainable Development Goals, such as poverty eradication, gender equality, good health for all, reducing violence, crime and inequalities, economic growth or sustainable cities.
- Alcohol use contributed to more than 300,000 deaths in the Americas region – with more than 80,000 of those involving deaths that would not have occurred if alcohol had not been consumed.
- Peru was among the countries experiencing the highest number of years lost due to ill-health, disability or early death.
Perceptions of key stakeholders on taxes on tobacco and alcohol products in Nepal
In order to adopt higher health taxes, the government will need to counter the false narrative pushed by alcohol and tobacco industries on the negative economic effects of such taxes. Health taxes earmarked for NCDs need to reflect the amount of revenue raised, reoriented towards prevention efforts and communicated clearly to the public.
Key findings
What is already known on the subject
- Health taxes have the potential to reduce the consumption of alcohol and tobacco products and help curb non-communicable diseases.
- In Nepal, health taxes are below WHO-recommended rates and among the lowest in South Asia.
What this study adds
- This study is among the first efforts to document the perceptions of key stakeholders on the use of taxes on alcohol and tobacco products in Nepal.
- Support for higher taxes on alcohol and tobacco products is limited, with evidence of industries employing various tactics to prevent tax increase and to sustain public support.
How this study might affect research, practice, or policy
- The study’s findings present advocates with several areas for action, in particular the need to publicise industries’ effort to undermine taxes and to general local evidence on economic effects of health taxes.
Framing health taxes: a scoping review
Health taxes are increasingly positioned as effective policy instruments for curbing non-communicable disease, improving health and raising government revenues.
Their allure has caused many health advocates to look beyond tobacco and alcohol to other harmful products such as sugar-sweetened beverages (SSBs), salty foods, fatty foods and fossil fuels. These efforts, however, directly conflict with commercial actors’ interests.
Both pro-tax health advocates and anti-tax industry lobbyists seek to frame health tax policy in favourable ways. Yet, little is known about which types of frames resonate in which settings, or how they deploy morals and values in their attempts to persuade. To fill this gap, the reseachers conducted a scoping review on framing health taxes using six databases in 2022.
A total of 40 peer-reviewed empirical research articles, from 2006 to 2022, were identified from 20 different countries. Most research was conducted in high-income countries, published in the last 4 years and increasingly focused on excise taxes for SSBs.
Studies captured multiple actors constructing context-specific frames, often tied to broader economic, health and administrative considerations. Actors also engaged in a range of political activities in addition to framing.
The study found some evidence that anti-tax framing strategies potentially incorporated a broader array of morals and social values. More in-country comparative research, particularly from low/middle-income countries, is needed to understand the politics of framing health taxes.
The researchers argue that these insights can improve efforts to advance health taxes by constraining corporate power, improving population level health and promoting greater social harmony.
Key findings
What is already known on the topic
- Health taxes have been shown to reduce the burden of non-communicable diseases and raise revenue around the world.
What this study adds
- This research shows that evidence is rapidly increasing, especially from high-income countries and for sugar-sweetened beverage taxes, about how to frame health taxes.
- This includes:
- developing grassroots arguments that resonate with local constituents,
- launching intensive media campaigns,
- reassuring voters that revenue generated from health taxes funds social programs,
- making greater use of health professional associations in health tax debates, and
- developing different kinds of frames that tap a broader array of morals and social values (instead of searching for a single strong frame).
How this study might affect research, practice, or policy
- This research will help health advocates think strategically about ways to frame different features of health tax policy in order to generate support from lawmakers and the general public.
