The passage and implementation of a Health Promotion Levy in South Africa as a case study of fair financing procedures

Abstract

Procedural fairness is an accepted requirement for health decision-making. Fair procedures promote the acceptability and quality of health decisions while simultaneously advancing broader goals of participatory democracy. We conducted a case study of the Sugary Beverage Tax in South Africa known as the Health Promotion Levy (HPL), which was legislated in 2018. The case study examines the process around the adoption of the HPL from the perspective of procedural fairness with the view of identifying local gaps and lessons transferable to other local decision-making processes and other jurisdictions. We conducted a desk review of publically available data relating to the passage and implementation of the HPL, including a review of the policy documents, public submissions during the public participation process, response documents from policymakers, review of national legislative committee minutes, legal instruments and academic literature capturing public awareness, stakeholder views and media content. The data collection is novel in terms of the large scope of data considered, as well as the variety of sources. An analytical framework consisting of key criteria for procedural fairness, informed by a scoping review of the literature, guided the analysis of the decision-making process in South Africa. The process of the adoption and passage of the HPL met the majority of the procedural fairness criteria. However, a shortcoming, which impacted several criteria, was the failure to actively source the participation of community representatives and the larger public. Non-governmental organizations did not adequately fulfil this representative role. Industry interests were also disproportionately considered. The case study highlights the overall importance of viewing general members of the public as interested parties in health policies and the dangers of over-involving policy opponents under a mistaken understanding that this constitutes meaningful public engagement in decision-making procedures.

Developing the improved Community Health Fund in Tanzania: was it a fair process?

“…However, in the case of iCHF, there were little publicity when key features were developed and agreed and no publicly available documentation of the process. Discussions of the rationale for the chosen approach and key features of the design of iCHF were limited to the technical working group and were not shared widely, as it was done, for instance, in the case of South Africa’s Health Promotion Levy ( MoF, 2017 ; Kruger et al. , 2023 ).…”

Procedural fairness in health financing for universal health coverage: why, what and how

“…The first is a revenue mobilization decision: the choice to introduce a tax on sugar-sweetened beverages (SSBs). Kruger et al (2023) explore the procedural fairness of South Africa’s decision to introduce an SSB tax—the Health Promotion Levy. They highlight the critical role played by a well-defined legislative process with public consultations mandated by constitutional provisions.…”