The Ghanaian Parliament on December 20, 2022, tabled, debated, voted, and approved (for the second time) a Bill to tax Sugar-Sweetened Beverages (SSBs) and other products – as per the Ghana Excise Duty Amendment Bill, 2022. Over the past four weeks, I have presented my take on this policy intervention. In my most recent post, I shared with you a Position Statement that the Advocating for Health (A4H) Coalition submitted to the President of the Republic of Ghana and key Government Ministries, Departments, and Agencies. The Coalition comprises the A4H Project, the Healthier Diets for Healthy Lives (HD4HL) Project, and others including the Coalition of Actors for Public Health Advocacy (CAPHA). This week, I share with you a Press Statement by the Coalition. Please take a few minutes to read the statement (reproduced below).
PRESS RELEASE
Accra, Ghana – February 8 2023. The Advocating for Health (A4H) Coalition. info@advocating4health.org
Taxation of Sugar-Sweetened Beverages is a Win-Win-Win Strategy for Public Health, for Government Revenue, and for Health Equity
The Advocating for Health (A4H) Coalition – comprising academics from five public universities in Ghana (led by the University of Ghana, School of Public Health) and their international partners, civil society organizations (including the Ghana NCD Alliance), nutrition societies (including the Ghana Academy of Nutrition and Dietetics), and public health associations (including the Ghana Public Health Association) commend the Government of Ghana for the proposal to tax health-harming commodities and products including sugar-sweetened beverages (SSBs). As health costs and deaths linked to these products mount, this is the right intervention to protect, promote, and assure public health.
Non-communicable diseases are a major cause of death, and disability globally, and are predicted to become the leading cause of death in Africa by 2030. Ghana is experiencing a surge in diet-related NCDs, amidst challenges of food insecurity, micronutrient malnutrition, and infectious morbidities. Several local studies report a high prevalence of overweight and obesity among Ghanaians, ranging from 16% to 46% for children aged 6 – 15 years and 25% to 47% for adults aged 15 years or older. One of the studies reported a 50% co-morbid conditions of diabetes and obese in Ghanaian adults. People (particularly children) who suffer from overweight or obesity have an elevated probability of developing other diet-related NCDs such as type 2 diabetes, hypertension, and stroke in later life.
SSBs are a significant contributor to overweight, obesity and other diet-related NCDs (including dental caries). While the determinants of these conditions are many, dietary factors such as excessive consumption of calorie-dense, nutrient-poor foods (including SSBs) are the most important. The true economic and health costs of SSBs are staggering. A team of Ghanaian researchers recently estimated the direct healthcare costs associated with obesity in older adult Ghanaian population to be very high. Compared with healthy-weight adults, overweight and obesity were associated with 75% and 159% more in-patient admissions, respectively. For adults with healthy weight, the average per person health care cost per admission was $35, whereas for adults with overweight it was $78, and adults with obesity, $132. The researchers also estimated that 60% of the average total cost per person expended in 2014/2015 was borne by the National Health Insurance Scheme (NHIS). Extrapolating to the entire older adult Ghanaian population (aged 50+ years), the total direct healthcare cost burden for overweight and obesity was $121 million compared with $64 million for normal weight. This implies that the Government of Ghana is paying for these preventable, expensive health conditions when lives and money could be saved with preventive policies such as SSB, tobacco and alcohol taxes.
Concerned about this, the World Health Organization (WHO) has recommended that adults and children limit their intake of free sugars to less than 10% of their total energy intake per day. Per WHO definition, free sugars “includes monosaccharides and disaccharides added to foods and beverages by the manufacturer, cook or consumer, and sugars naturally present in honey, syrups, fruit juices and fruit juice concentrates”. As part of its bundle of “Best Buys and Effective Interventions”, the WHO has also recommended Health Taxes (including taxes on SSBs) as an intervention to reduce the consumption of sugars and other foods implicated in obesity and NCDs.
As of May 2022, over 80 countries and jurisdictions (including subnational levels) had levied taxes on SSBs. Data from these jurisdictions that have enacted SSB taxes correlate the implementation of the tax with decreased consumption of SSBs, and a corresponding increase in purchases and consumption of untaxed healthier products (including water) as well as a good revenue stream for Government.
For instance, in October 2013, the Mexican Government passed legislation to introduce a specific excise tax of one peso (about US$ 0.05) per litre on SSBs, equivalent to a 10% price increase on taxed beverages. The success of the tax in reducing purchases and consumption of SSBs has been widely reported.
In 2018, South Africa introduced a specific excise tax on SSBs, to tackle rising intakes of such beverages and a growing burden of diet-related NCDs. An evaluation conducted between 2014 and 2019 found that the average volume of taxable beverages purchased, as well as the calories and sugar purchased from taxable beverages fell drastically after the tax. Other African countries including Mauritius, Seychelles, Morocco, Botswana, and Nigeria have enacted SSB tax policies. Of note, in all countries, the process of enacting SSB tax laws is usually met with emotive oppositional arguments.
Some of the popular oppositional arguments to SSB tax policies usually by industry actors and their surrogates have mirrored what has been referred to as the S.C.A.R.E tactic. These actors would attempt to Sow doubt by discrediting science and diverting attention; they adopt Court and legal challenge threats; they resort to Anti-poor rhetoric (e.g. that SSB tax is regressive); they argue that tax will result in Revenue instability; and that it will impact on Employment negatively. All of these have been debunked (see an evidence-informed policy brief developed by the WHO titled “Fiscal Policies to Promote Healthy Diets” and our evidence-grounded “Position Statement” dated December 30 2022)
On revenue instability: It is often argued that “taxes will not yield the expected revenue, or increases to existing taxes may reduce revenue yields”. It is worthy of note that “the impact on revenues of taxes to promote healthy diets depends largely on how the tax is designed and administered. Country experiences indicate that these taxes can generate additional revenue, which can then be used to finance health or social initiatives”.
Regarding impact on employment: It is a common argument that “taxes on less healthy foods and beverages will increase prices and reduce sales, affecting employment”. On the contrary, available evidence shows that “because taxes encourage consumers to substitute taxed foods and beverages for healthier foods and beverages, demand for healthier options may increase, providing opportunities for the food industry to offer such options and for jobs to be derived from the increased demand for these products. Consumers may also spend money they would have spent on taxed foods and beverages on other goods and services, increasing employment opportunities in other industries”.
Other have argued that there is no absolute or conclusive evidence, and that policy makers should hasten slowly: Granted that the evidence is not absolute we deem it apropos to invoke D. G. Altman and J. M. Bland here that, “absence of evidence is not evidence of absence”. The WHO has also recently warned that “delaying SSB tax implementation for the causal evidence linking it to improved health outcomes is risky given the current rise in NCDs and patterns of unhealthy food consumption. By the time absolute evidence is available, it might be too late”.
The A4H Coalition is well aware of the actors and their vested interests. We are aware that the power asymmetries between “public” and “private” interests sometimes confound promulgation and implementation of public health policies. While the object of this Press Statement is not to rebut the oppositional arguments recently put forward by industry actors, it is important to recognize that the food industry, with a fiduciary duty to deliver profits by selling food (healthy or otherwise), cannot be a dependable partner in policies that ultimately aim at reducing the sales of those products. Indeed, evidence abound regarding how efforts to develop public policies to limit consumption of unhealthy commodities have been undermined by private sector actors
As health costs and deaths linked to health-harming products (such as SSBs) mount, we urge the Government of Ghana to not relent in getting the Excise Duty Amendment Bill enacted. The government of Ghana does not only have an opportunity to enact and implement this policy, but a responsibility to do so. It is the responsibility of every government to protect, promote, and guarantee the health of its citizens – as per their national constitutions, legislation, regulations, and policies, as well as international conventions.
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