Health Taxes on Tobacco, Alcohol, Food and Drinks in Low- and Middle-Income Countries: A Scoping Review of Policy Content, Actors, Process and Context

Abstract

Background: Taxation of tobacco, food, alcohol and other beverages has gained renewed attention in responding to non-communicable diseases (NCDs). While largely built on evidence from high-income countries (HICs), the projected economic and health benefits of these measures have increased calls for their use in price-sensitive low- and middle-income countries (LMICs). However, uptake has been sporadic and there remains little research on why and how LMICs utilise fiscal measures in response to NCDs. Methods: This scoping review analyses factors influencing the design and implementation of health-related fiscal measures in LMICs. Utilising Arksey and O’Malley’s scoping review methodology and Walt and Gilson’s policy triangle, we considered the contextual, procedural, content and stakeholder-related factors that influenced measures. Results: We identified 75 papers focussing on health-related fiscal measures, with 47 (63%) focused on tobacco, 5 on alcohol, 6 on soft drink and 4 studies on food-related fiscal regulation. Thirteen papers analysed multiple measures and most papers (n = 66, 88%) were less than a decade old. Key factors enabling the design and implementation of measures included localised health and economic evidence, policy championing, inter-ministerial support, and global or regional momentum. Impeding factors encompassed negative framing and retaliation by industry, vested interests and governmental policy disjuncture. Aligning with theoretic insights from the policy triangle, findings consistently demonstrated that the interplay between factors – rather than the presence or absence of particular factors – has the most profound impact on policy implementation. Conclusion: Given the growing urgency to address NCDs in LMICs, this review highlights the need for recognition and rigorous exploration of political economy factors influencing the design and implementation of fiscal measures. Broader LMIC-specific empirical research is needed to overcome an implication noted in much of the literature: that mechanisms used to enact tobacco taxation are universally applicable to measures targeting foods, alcohol and other beverages.

The Lancet Global Health Commission on financing primary health care: putting people at the centre

“…However, in the meantime, these can raise revenue that can be earmarked for health if political economy considerations and budgetary rules are aligned. 87 According to the World Bank, an increase in excise taxes on tobacco, alcohol, and sugar-sweetened beverages that would result in a 50% increase in prices could raise the tax–GDP ratio by an average of 0·7 percentage points in low-income countries and LMICs. 72 Other taxes could also be explored for the health sector, such as taxes on transport and airline levies 88 or on carbon emissions.…”

Normalizing the political economy of improving health

“…Indeed, more rigorous exploration of political economy factors and an understanding that how health taxes are framed can shape their implementation is needed. 10 To help rectify this, in 2021 the Alliance for Health Policy and Systems Research, a WHO-hosted partnership, launched a programme of work to identify and build the capacity of local health researchers, as a way to support policy-makers in communicating and advancing health taxes.…”

Linking health and finance ministries to improve taxes on unhealthy products

“… 7 The priorities of health and finance policy-makers differ in that finance policy-makers have a mandate to consider the economic interests of industry. 8 Representatives from the relevant manufacturing industries may claim that high taxation increases illicit trade, pushes consumers to seek cheaper alternatives, and punishes legitimate businesses. 9 In the United Kingdom of Great Britain and Northern Ireland, arguments against the soft drinks levy from representatives of the sugar-sweetened beverage industry were reminiscent of those used by the tobacco and alcohol industry, and included efforts to undermine public health evidence and the effectiveness of health taxes.…”