| dc.description.abstract | Globally, health taxes have proved a popular and effective intervention for reducing non-communicable disease (NCDs). Specifically, implementation of taxes on sugar-sweetened beverages (SSBs)/energy-dense food has significantly increased in the last two decades in countries around the world. With their implementation, several parallels to tobacco and alcohol taxes can be seen. First, these taxes are recommended as part of a comprehensive package of policy tools targeting reduced consumption. Second, they have been largely successful in reducing demand and hence diet-related NCD risk factors and third, they are effective at generating significant revenue.
Despite the growing number of governments adopting this administratively feasible policy tool there are still policy-makers who hesitate, primarily due to uncertainty about equity concerns around regressivity and industry claims of job loss and economic downturn. Furthermore, industries involved in the manufacture and supply of these products fiercely oppose taxes based on the broad argument of decreased sales and thus, reduced profits. Evidently, this creates a tension between health and economics goals. Thus, effective and sustainable design and implementation of health taxes must be underpinned by a more nuanced understanding of the political and economic drivers influencing the policy process and the key actors involved.
This thesis addresses the paucity of evidence relating to policy landscapes, contextual political economy and the use of evidence relating to impact of health taxes for NCD prevention globally, and particularly in lower-middle income countries. The primary aim of this thesis was to address questions relating to the use and acceptability of SSB taxes from a politico-economic perspective. In addition, we addressed the question of what evidence relating to the health and economic impact of SSB taxes could be used by policy-makers to support the strengthening, scale up and acceptance of SSB tax policies. The thesis aim was addressed through two comprehensive reviews of relevant literature, two qualitative studies and an economic modelling study. Together, these represented both a much-needed contribution to the literature, and an integration and assimilation of evidence for policy-makers in two Pacific Island countries, Fiji and Tonga.
This is a mixed methods thesis comprising four main methods. First, two reviews of the global literature were conducted: (i) a book chapter, developed around a simple but comprehensive conceptual framework, reviewed the evidence of the labour impacts of health taxes, and (ii) a systematic review mapped out the macroeconomic impacts of diet-related fiscal policy. The second and third methodologies involved qualitative analyses. The thesis drew on well-established theoretical frameworks relevant to political economy and policy analysis and utilised established corporate political activity conceptual frameworks to identify and analyse industry activity. The final methodology was a quantitative modelling analysis. The modelled estimates of health and economic impacts of SSB taxes in Fiji were derived from a proportional multi-state life table (pMSLT) Markov chain modelling approach adapted from an existing Excel-based model. Four scenarios of various SSB tax levels that align with World Health Organization recommendations for effective SSB taxation (between 20% and 50%) were modelled and changes against a (baseline) tax were estimated.
The two reviews of the global literature contributed much needed information to counter broadly, industry arguments during the tax policy implementation process. They found that the majority of the evidence for negative labour and macroeconomic impacts from health taxes came from industry reported studies utilising inappropriate methodology showing partial, gross impacts. More robust studies found no evidence of significant negative labour or macroeconomic impacts and indeed, some studies found small but significant increases.
The comparative political economy analysis helped to fill the wider gap in the literature on what helps (or not) public health researchers and policy-makers implement effective SSB and diet-related taxes. Common findings to both Fiji and Tonga suggested improved SSB tax implementation through multi-sectoral engagement, embracing a whole-of-society approach, strengthened institutional structures and leveraging off competing priorities across sectors towards more common goals.
This thesis then focused on Fiji specifically to generate two contextual sets of research findings. First, the policy landscape analysis identified key factors for strengthening diet-related NCD policies more broadly in Fiji, including ensuring a nutrition- and health-in-all policy approach, using a whole-of-society approach to tighten political action across sectors and importantly for Fiji, to identify and counter food industry influence.
Second, the modelling of SSB taxes in Fiji complemented the policy landscape analysis to show that SSB taxes were predicted to improve the incidence, prevalence and mortality associated with obesity-related disease in Fiji as well as creating significant revenue. Overall and for all health outcomes, the greatest benefits came from the FJ$2.00/litre + 50% ad valorem tax. The least were predicted from the FJ$ 0.35/litre tax. In a population of approximately 900,000, reductions to obesity prevalence ranged from -1512 (males) and -1668 (females) cases to -8551 cases (males) and -9,527 (females). Overweight prevalence reduction ranged from -845 (males) and -195 (females) to -5662 (males) and -1737 (females). Over the first 25 years, reduced prevalence of overweight and obesity in the Fijian adult population had the largest impact on type 2 diabetes mellitus (T2DM) incidence, prevalence and mortality followed by ischemic heart disease (IHD) and stroke. Incidence of T2DM reduction ranged from approximately -4500 cases to nearly -26,000 cases. Ischemic heart disease incidence reduction ranged from -259 (95% UI -352 to 191 cases) total cases to -1482 (95% UI -2,008 to -1,113 cases). Reductions in stroke incidence ranged from -94 cases (95% UI, -134 to -65 cases) to -540 cases (95% UI, -726 to -385 cases). Our modelling suggested modest reductions in overall mortality across the tax scenarios over 25 years and ranged from a reduction of -215 deaths (95% UI, -274 to -165 deaths) to -1214 deaths (95% UI, -1514 to -986 deaths). Revenue generated ranged from approximately USD 105 million over 25 years, discounted at 3% (undiscounted, USD 141 million) to approximately USD 452 million (discounted at 3%) or approximately 605 million undiscounted with the 100% ad valorem tax scenario. The scenarios demonstrated that over 25 years, a gain of HALYS in the range of approximately 4000 HALYs to approximately 24,000 HALYs would be achieved.
In summary, this thesis makes a significant contribution to the emerging literature on the politico-economic insights of health and diet-related fiscal policy. First, the thesis highlights how industry, with a goal of financial growth, creates and influences significant and wide-ranging opposition for the effective implementation of health and fiscal policy. Second, the thesis counters these opposing politico-economic influences by identifying opportunities policy-makers can embrace to strengthen and/or scale up fiscal policy interventions despite the negative industry influence, including building capacity relating to the use of evidence, and strategically framing the benefits of the tax. Finally, the thesis presents estimates of the expected benefits to the health of the Fijian population and the revenue generated - both of which stand to contribute to the strategic direction of economic growth of the Government of Fiji. The findings illustrate important lessons for similar settings seeking to strengthen or upscale the impact of diet-related fiscal policy. | en |
