Could food-related health taxes change food choices in Ghana?

As the COVID-19 pandemic continues to affect every corner of the globe, researchers have uncovered evidence about the routes of transmission, virulence, and short- and long-term consequences for those infected. Some of the major findings in COVID-19 research were around pre-existing non-communicable diseases (NCDs) such as type 2 diabetes, cancer, obesity, and hypertension. Scientists found that many NCDs present risk factors that can make the virus deadlier for some (Dietz & Santos-Burgoa, 2020). As of 16 April 2021, there have been approximately 138.4 million cases worldwide and 2.97 million deaths (World Health Organization, 2021). Vaccination campaigns have commenced, but supply, storage and distribution have posed significant logistical challenges for much of the world. Aside from the vaccine, experts currently advocate adherence to mask mandates and social distancing, as the primary means of preventing infection (Cartaud, Quesque, & Coello, 2020; Jean-Jacques & Bauchner, 2021). Responding to the pandemic, governments in many cities and countries imposed various containment measures, including partial or complete lockdowns, travel restrictions, and school closures. These have been met with extreme criticism; critics cite job losses and associated negative economic and social consequences.

A relatively underemphasized public health concern that is linked to the pandemic is the increased consumption of unhealthy foods and beverages (Pellegrini et al., 2020). There are several potential reasons for the rise in unhealthy food choices during the pandemic. First, due to lockdowns and other restrictions, food systems have experienced significant disruptions in supply and demand, and needless to say, consumer access to healthy and fresh food has been challenging in some places (Barrett, 2020; Béné, 2020). Our earlier scenario-based commentary outlined the potential long-term impacts of the COVID-19 pandemic on the nutritional status of Ghanaian children.  (Quarpong, Tandoh, Amevinya, Rampalli, & Laar, 2020). Scenario 1 hypothesized that with pandemic restrictions limiting food access, a reduced food intake will result in undernutrition. Scenario 2 outlined the potential impact of the pandemic on increased consumption of ultra-processed foods, increased overall food intake, reduced physical activity and their combined impact of weight gain (Monteiro et al., 2019; Quarpong et al., 2020). Second, families around the world have experienced significant economic hardship as many livelihoods have shifted as part of the pandemic response. Disposable incomes have fluctuated, and many families have experienced food insecurity as a result of reduced incomes. As a result, many families have chosen to stock their homes with packaged and other non-perishable ultra-processed foods that have a long shelf life, are cheaper, and easier to find in both high-income and low- and middle-income countries (LMICs) (Balde, Boly, & Avenyo, 2020; Mandel & Veetil, 2020). Third, with many children and adults stuck indoors during the pandemic, the combination of stress, anxiety, boredom, and discomfort have led many people down a path of emotional eating, particularly of junk food  (Cecchetto, Aiello, Gentili, Ionta, & Osimo, 2021; Gunderson & Ziliak, 2015; Pellegrini et al., 2020; Rundle, Park, Herbstman, Kinsey, & Wang, 2020).

It is well known that for the last three decades, nearly all countries have experienced growing burdens of diet-related NCDs concurrently with changing dietary trends accelerated by obesogenic food environments (Dake, Thompson, Ng, Agyei-Mensah, & Codjoe, 2016; Kroll et al., 2019; Popkin, 1998; Popkin, Adair, & Ng, 2012; Turner et al., 2019). This includes the widespread consumption of sugar-sweetened beverages (SSBs), packaged and ultra-processed foods high in refined carbohydrates including added sugars, sodium, and saturated and/or trans fats (High Level Panel of Experts on Food Security and Nutrition, 2017; Monteiro et al., 2019; Popkin et al., 2012). Consumption of these categories of foods have been closely linked to increases in NCDs including obesity, type 2 diabetes, cardiovascular disease, and dental caries (Teng et al., 2019; Vorster, Kruger, & Margetts, 2011; Willett et al., 2019). UNICEF reports that poor diets are having extremely adverse effects on children worldwide, with 42% of school-going adolescents in LMICs consuming sugar-sweetened beverages daily and 46% eating fast food weekly. Needless to say, rates of overweight and obesity among children has doubled from one in ten in the year 2000 to one in five in the year 2016 (UNICEF, 2019).

Ghana is no exception to the aforementioned global trends of rising diet-related NCDs (DR-NCDs) alongside the proliferation of modernized food environments. The Ghana NCD Alliance reports that 43% of all deaths in the country are due to adult-onset NCDs, with DR-NCDs contributing to approximately half of those deaths (Akoloh, 2019; Ghana NCD Alliance, 2020; World Health Organization, 2018). Studies by Alangea and colleagues (2018) and Aryeetey and colleagues (2017) also found a high prevalence of unhealthy, energy-dense (often heavily processed) foods consumed by urban Ghanaian schoolchildren (ages 9-15), which is of concern due to the growing rates of child and adolescent obesity (Aryeetey et al., 2017; Ogum Alangea, Aryeetey, Gray, Laar, & Adanu, 2018).  The government of Ghana is aware that DR-NCDs are a serious public health problem but are in very preliminary stages of considering measures to improve food environments for Ghanaian children. In fact, Laar and colleagues (2020) used the International Network for Food and Obesity / Non-communicable Diseases (NCDs) Research, Monitoring and Action Support (INFORMAS) Healthy Food-Environment Policy Index (Food-EPI) tool to find that one of the most successful food environment measures implemented by the Ghanaian government is the restriction of the marketing of breast milk substitutes (INFORMAS, 2021; Laar et al., 2020). Other measures, such as transparent nutrient labeling, incentivizing healthy foods and disincentivizing unhealthy foods, and enforcement of zoning laws to limit unhealthy food sales, were considered “very low” and hindered by resource constraints including funding and political will (Laar et al., 2020; Swinburn et al., 2013).

The World Health Organization has promoted various food policies to respond to the rising global burden of NCDs. One of the key policy initiatives which has gained traction in recent years is the levy of taxes on unhealthy food and beverages. Sometimes referred to as a “sin tax”, “health tax,” “fat tax,” or food-related health tax, this policy initiative seeks to curb excessive consumption of foods high in added sugars, sodium and/or saturated and trans fats. The rationale for the policy is that if cost is a significant food choice consideration, then a higher cost on the item would deter purchasing of it, thus reducing demand for and overall consumption. Revenues from the taxes may then be used to fund health sector prevention and treatment programs for NCDs (Allcott, Lockwood, & Taubinsky, 2019; Edwards et al., 2016; Teng et al., 2019).

Historically, taxes on unhealthy consumer products have been done with variable effects. One of the most popular goods to tax due to their unhealthiness are cigarettes and related tobacco products. In countries such as the United States, high prices of tobacco products have deterred many young people from taking up smoking and led many existing smokers to kick their habit. For example, according to the nonprofit tobacco cessation organization, Truth Initiative, for every 10% increase in cigarette prices, consumption reduces by 3-5% (Allcott et al., 2019; Delobelle, 2019; Truth Initiative, 2019). However, the taxes on tobacco products have been characterized as regressive and can have variable levels of effectiveness in behavior change based on socioeconomic status (SES). For example, those of lower SES tend to have a more significant and faster reduction in smoking due to higher prices, however, the decrease was not sustainable and many relapsed over time. Those of higher SES are largely unaffected by the price increase and continue to smoke (Blakely & Gartner, 2019).

Food-related health taxes have been deployed in many parts of the world, particularly in Europe and North America, for specific products (e.g., soft drinks or salty snacks), or for a food ingredient (e.g., added sugars, sodium, saturated fats) (Cornelsen, Green, Dangour, & Smith, 2015; Crouth, 2021). There is particular advocacy and support for the introduction of taxes on sugar-sweetened beverages, which evidence suggests can reduce consumption, although there is some debate on the matter (Backholer & Martin, 2017; Cornelsen & Smith, 2018; Du, Tugendhaft, Erzse, & Hofman, 2018). As of  2019, SSB taxes had been implemented in 40 countries (World Cancer Research Fund International, 2021). Proponents of the tax argue that much like tobacco taxes, the population, or at least some section of the population would be more sensitive to price changes (Blakely & Gartner, 2019). Critics argue that these taxes would only promote consumption of equally or more unhealthy food items, and that the taxes are difficult to enforce if the food outlets are poorly regulated (e.g., informal sector vendors) and do not undergo routine health inspections (Fletcher, 2011). Additionally, some critics of fat taxes argue that they are too paternalistic, and that people should have the freedom to consume what they want to consume and make their own decisions (Cornelsen et al., 2015).

Evidence in Africa is sparse about the effectiveness of such policies, and whether they are enforceable, given the vast number of informal sector food vendors. South Africa was the first (and currently the only African country) to have successfully introduced an SSB tax. Both Du and colleagues (2018) and Walls and colleagues (2020) describe details of the tax and how it took nearly two years from proposal to implementation (2016-2018) (Du et al., 2018; Walls et al., 2020). The fervent resistance from food companies to the implementation of the tax resulted in industry’s use of various tactics to counter the arguments made by advocates of the tax. In South Africa, the tax is applied after the first four grams of every 100mL of liquid, and each gram thereafter is taxed at ZAR 2.2 cents per gram. It has had promising results but there is still a call by public health experts to increase the levy from the current 11% to the WHO’s recommended 20% to have a stronger impact (Crouth, 2021). Of note, asymmetries of power/power dynamics between public health and private interests have been identified as an important driver behind the 2019 repeal of a proposed sugar-sweetened beverage tax policy in Morocco in 2018 (Bazza, 2018).

Recently, the legislatures of Oaxaca and Tabasco states in Mexico passed policies to ban sales of junk food, including SSBs, to minors (Fredrick, 2020). According to the Organisation for Economic Cooperation and Development, almost three-quarters of Mexico’s population is overweight (Salgado et al., 2020). The National Institute of Public Health of Mexico (INSP) reports that Mexicans consume more SSBs per capita than anywhere else in the world – approximately 163 liters per year, which amounts to about half a liter per day (CEVECE, 2013). SSB companies such as Coca-Cola have such advanced supply chains that they are able to deliver their products to the most remote areas of Mexico and many other LMICs at prices that are cheaper than potable water (Lopez & Jacobs, 2018). The bill is currently awaiting signature by the governors and there are at least a dozen other states in Mexico that are looking to enact similar bans.

Could the food-related health tax work to improve diets in Ghana? Like Mexico, Ghana is at an advanced stage of nutrition transition, experiencing rapid urbanization, and increasing overweight/obesity and related NCDs. Overall, overweight/obesity among women aged 15-49 years has increased by about one-third in a decade (from 25% in 2003 to 40% in 2014) (GSS; GHS; ICF International, 2015). Such increases have been linked to unhealthy energy-dense, nutrition-poor diets. It appears that if cost is a key food choice consideration for families, then higher prices might deter the purchase of unhealthy foods and beverages. However, some economists worry about the ‘substitution effect,’ in which higher prices for one good would cause higher consumption of another equally unhealthy item (e.g., if the prices for soft drinks were raised but the prices for sugar-sweetened juices stayed the same, the latter may be purchased in larger quantities) (Fletcher, 2011). While Ghana’s Ministry of Health NCD policy (2012-2016) briefly mentioned the intent to introduce such taxes, decisions about implementation and logistics have yet to be made (MoH Ghana, 2012). In recent years, various civil society organizations have put pressure on the government to consider implementation of this and related taxes (Akoloh, 2019; Business Ghana, 2019; Ghana NCD Alliance, 2020; Ola-Morris, 2019). While recognizing that contexts differ, we believe Ghana’s effort at introducing food-related health tax will benefit from the experiences shared (particularly of Morocco and South Africa). We have learned that, but for the concerted evidence-informed advocacy that was undertaken by civil society, academia, and other stakeholders in support of the tax, the initiative would have stalled (Du et al., 2018).

Given the compelling public health rationale for governments to embrace SSB taxes, these local efforts to introduce the tax should be supported. However, contextual, locally generated evidence is needed to support both the civil society advocacy efforts, as well as provide elucidation to the Ghanaian policymaker of the policy rationale and impacts. To that end, the Measurement, Evaluation, Accountability, and Leadership Support for NCDs Prevention Project (MEALS4NCDs) is currently generating the needed evidence to support public sector actions (including fiscal policies) that create healthy food environments in Ghana. In collaboration with the Coalition of Actors for Public Health Advocacy (CAPHA), this coalition of coalitions is well placed to support Ghana’s food-related health tax initiative.

This article was written by Krystal Rampalli, Wilhemina Quarpong, Phyllis Addo, Akua Tandoh, Gideon Amevinya, and Amos Laar.


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