Do Not Relent, Get It Done to Promote, Protect and Guarantee the Health of Ghanaians, as Health Costs and Deaths Linked to Diet-Related Non-Communicable Diseases Mount.

“In this world, nothing is certain but death and taxes” – Benjamin Franklin once said. On ‘taxes’, it is a common refrain in daily conversations of Ghanaians – as they lament “over-taxation”. An associate of mine once noted: “when one makes money, one gets taxed, when one spends, one gets taxed, and when one saves, one gets taxed, do they want us to run out of this country or what?”. As reported by Ntiamoah (2016) and Wanjohi et al (2021), some consumers have cautioned that, tax whatever you may, but not ‘food’. Can food be taxed? Without hesitation yes, and health-harming food should be heavily taxed if it’s unlawful to outlaw the sale of such foods. Referred to as health taxes, levies on unhealthy food is a special kind of tax. In general, health taxes are levied on products that adversely affect health, most notably tobacco, alcohol, non-alcoholic beverages, gambling, and unhealthy foods (WHO, 2017; WHO 2019). Sometimes referred to as “sin tax”, “fat tax,” “soda tax”, or food-related health tax, when levied on food, this policy initiative seeks to curb excessive consumption of unhealthy foods, or foods high in nutrients of concern such as sugars, sodium, saturated fatty acids, and trans fatty acids). The rationale for the policy is that if cost is a significant food choice consideration, then a higher cost on a food item would deter purchasing it, thus reducing demand for, and consumption of the food. Secondarily, revenues from the taxes can be used to fund health sector prevention and treatment programs for harms caused by consumption of such foods (Allcott, etal 2019; WHO, 2019).

On ‘death’, everyone will die at some point, but it should not be from preventable causes, particularly from the food we eat. Diets – the foods that are consumed, or are recommended to be consumed by humans, were not meant to kill. Detailed during the fourth century (B.C.E), we have the benefit of reading today about what was considered an appropriate diet. Quite recently a group of experts recommended as healthy diets, “diets that are largely consisting of vegetables, fruits, whole grains, legumes, nuts, and unsaturated oils, low to moderate amount of seafood and poultry, no or a low quantity of red meat, processed meat, refined grains and added sugar”. Without a doubt, sugars, particularly in liquid form, but more broadly, sugar sweetened beverages (SSBs) such as regular soda or soft drinks, fruit drinks, sports drinks, energy drinks, and sweetened waters are harmful to health. These products can, and should be taxed. The consumption of SSBs is a risk factor for several diet-related non-communicable diseases (NCDs) such as obesity, diabetes, hypertension, cardiovascular disease and many common cancers (WHO, 2015; Te-Morenga et al 2012; Malik et al 2017. On average, a single can of a sugary drink contains up to 40 grams of granulated sugar equivalent to around 10 teaspoons or 10 cubes of table sugar (WHO, 2017). Few, if any, would fetch 10 or 20 or 30 teaspoons of sugar and gulp it down, and yet many do in the form of SSBs. A friend once asked, “If you will not take 20 cubes or 20 teaspoons of sugar, why take two or three, or four cans of a sugary drink daily”? My response: those who do, do not know they are gulping down several cubes of sugar. For more information see Grethe Koen’s Sugar Scale. No one would like to take their money and buy sickness. I reiterate that the consumption of SSBs is harmful to health.

Urgent action is needed to curb the rise of NCDs, and thus reach the global NCDs targets, that Ghana has endorsed. These targets include the World Health Assembly targets of “halting the rise of obesity and diabetes; reducing premature deaths from NCDs by 25% by 2025; and the Sustainable Development Goals(SDGs) target of “reducing premature deaths from NCDs by one-third by 2030”. Taxes (particularly food-related health taxes such as SSB taxes) have been recommended by the World Health Organization (WHO) as an effective intervention to reduce the consumption of sugars and other foods implicated in obesity and NCDs WHO, 2017). Usually paid at the time of purchase, currently, several countries have enacted and are implementing SSB taxes, which evidence suggests, with some debate, reduces SSBs consumption (Backholer et al 2017; Du et al 2018) and generate a good deal of revenue for governments (Brownell et al 2009). If ring-fenced or earmarked, the revenue can be applied to address the harms caused by their consumption. Additionally, taxes on SSBs instigate their reformulation by industry. Below a nationally stipulated threshold, reformulated SSBs – SSBs with reduced amounts of sugar may not be taxed.

In Ghana, local evidence (GSS et al 2015; Adjei et al 2022; Amevinya et al 2022) show widespread availability, accessibility, relative affordability, and celebrity-endorsed advertisements of SSBs. These warrant urgent intervention by relevant actors, particularly, the government. The government of Ghana has an opportunity and a responsibility to act. Since 2012, the government pledged (in the first National Policy on NCDs, and Public Health Act – Act 851) to act. It is the responsibility of every government to protect, promote, and assure the health of their citizens – as per national legislations, policies, as well as international conventions (Laar, 2021). The WHO, other global, regional, and local health promoting institutions stand ready to support Ghana (and therefore, any jurisdiction desirous of protecting, promoting, and improving the health of their citizens).

The Advocating for Ghana’s Health (A4H) Coalition derives motivations from this. The Coalition comprises Academia (led by the School of Public Health, University of Ghana), Civil Society Organizations (led by the Ghana NCD Alliance), Public Health Associations (led by Ghana Public Health Association), Nutrition/Dietetic Professional Group (Ghana Academy of Nutrition and Dietetics), as well as the Coalition of Actors for Public Health Advocacy (CAPHA). With financial and technical support from the Global Health Advocacy Incubator, the A4H Coalition’s work seek to create a favorable environment and stakeholder buy-in for food-related fiscal policies (particularly SSB tax) in Ghana. The Coalition believes that if the Ghanaian government implements comprehensive policy measures that serve to limit availability of less healthy foods (e.g. energy-dense nutrient-poor foods, foods that contain too much salt, sugar, and harmful fats), while making available healthy foods (e.g. unprocessed, minimally processed foods including wholegrains, fruits, and vegetables); food actors (e.g. producers and consumers) will make immediate or strategic decisions to reduce availability, attractiveness and consumption of such less healthy foods, or increase availability, attractiveness, and consumption of healthier foods.

The Coalition is concerned about the escalating prevalence of overweight/obesity in Ghana particularly among women of childbearing age (this increased from 10% in 1993 to 40% in 2015. It’s troubled by the fact that dietary risk factors of NCDs, high blood pressure, elevated fasting plasma glucose and high body mass index are among the top 10 risk factors that drive the most death and disability combined, and alarmed by the increasing health and economic burden of these conditions (NCDs have been estimated as responsible for over one-third of all adult deaths in Ghana. Cognizant of the fact that currently available, albeit with patchy implementation, are several evidence-based interventions (WHO, 2017) to reduce the burden of NCDs among populations, the A4H Coalition has, and will not relent on its calls to the government of Ghana to implement evidence-informed interventions such as SSB tax to address their harms.

Informed by global and sub-regional evidence-informed guidance, the A4H Coalition specifically appeals to the government of Ghana:

to enact and implement SSB tax now
as per WHO guidance, recommends a tax rate of at least 20% to ensure a pass through rate of about 20%
to implement a specific excise tax (which may be volumetric or nutrient-based). Of note, in jurisdictions such as Ghana with strong tax administration, the WHO recommends specific excise taxes calculated based on nutrient content. Further, the WHO, and others have argued that, given that SSBs are a heterogeneous set of products containing variations in sugar levels, “taxing SSBs according to their sugar content more precisely targets the source of these products’ harms and implicitly incentivizes beverage manufacturers to reduce the sugar content of their products”
as national laws permit, earmark revenue accruing from the imposition of SSB taxes for health promotion interventions

It’s worthy of note that SSB tax intervention is one of a range of effective measures proposed by WHO to curb the threat of NCDs. Other interventions such as transparent and truthful nutrition labelling; marketing restrictions of unhealthy foods and beverages to children; fruit and vegetable subsidies; and physical activity policies must be pursued. Knowing what I do of the Ghana public health nutrition landscape and its variegated political economies, a simultaneous implementation of multiple ‘carrot and stick’ policies (preferably double-duty policies) – aimed at combating malnutrition in all its forms) will make the most impact. Thankfully, this philosophy is currently endorsed by the Ghana Ministry of Health through the Healthier Diets for Health Lives (HD4HL) Project that it’s implementing in partnership with others.

Where is the evidence in support of food-related fiscal policies?

This is one of the ‘popular’, yet weak oppositional arguments to the enactment and implementation of SSB tax policies. Drawing on lessons from governments that have successfully enacted or implemented the tax policy, I would like to assure the Government of Ghana that the policy action has direct benefits on public health, as well as positive externalities on revenue mobilization. If any, I am convinced as per available evidence that, the policy’s direct benefits and positive externalities significantly outweigh is negative externalities. It is a win-win-win policy – for government, for public health, and for industry. A healthy and productive public impacts positively on government’s revenue generation and utilization, but also on the ability of food industries to thrive. Given that there is ample evidence in support of food-related fiscal policies, as outlined below, anyone who opposes this public health intervention might have ulterior motives.

Evidence in support of food-related fiscal policies

Globally, several countries are implementing fiscal policies as well as other food environments policies (www.wcrf.org/buildingmomentum/) in response to evidence-informed calls from the research community, as well as global public health institutions such as the WHO. I outline here select examples of these policies – from across the globe. For more information on lessons on implementation of SSB tax, front-of-pack food labeling, and restrictions of food and non-alcoholic beverage marketing to children globally, please visit World Cancer Research Fund’s database here www.wcrf.org/buildingmomentum/.

Food composition policies are motivated by evidence linking unhealthy food supply systems to the rise in malnutrition. These policies aim to minimize energy-density and nutrients of concern (e.g. salt, fat, saturated fat, trans-fats, added sugar) in processed foods. In 2014, the Argentine Government successfully passed a law on mandatory maximum levels of sodium for various food products. Several countries currently ban the use of trans-fats in foods. In 2013 (South Africa) and in 2019 (Morocco) adopted mandatory targets for salt reduction in several food categories including bread, breakfast cereals, margarines, savoury snacks, processed meats, dry soup and gravy powders and stock cubes. The 2020 WHO Global NCD Progress Monitor report limited government efforts in implementing these policies. According to this report, in Africa only Tunisia, and Morocco reported fully implementing salt/sodium policies (Tunisia) and saturated fatty acids/trans-fats policies (Morocco and Tunisia).

Noted, earlier, food-related fiscal policies (including levies on unhealthy foods and subsidies on healthy foods) promote and assure health outcomes by helping to make healthy eating choices easier and cheaper. Beginning in 1981 in Norway, several other countries have since used fiscal policies, as a major approach to curbing consumption of SSBs. Currently nearly 50 countries and smaller jurisdictions have enacted and implemented SSB tax. Such taxes have been shown to be impactful when well designed and implemented (Cabrera et al;. 2013; Colchero et al 2019). In 2014, Mexico introduced a tax of 10% or 1-peso-per-litre tax on beverages containing added sugar. An analysis of Mexican sugary beverage sales showed about 6% reduction in purchased volume relative to pre-tax trends over the first year of the tax, and a 9.7% decrease in 2015 (Colchero et al 2017). The largest decrease in purchases was amongst the most socioeconomically disadvantaged. Implemented since October 2014, the Chilean SSB tax (18% ad valorem tax on sugary drinks containing >6.25 g sugar/100 mL) was able to reduce the monthly purchased volume of the higher taxed, sugary soft drinks by 21.6%. Of note, the Chilean SSB tax includes all non-alcoholic drinks with added sweeteners (exempts 100% fruit juice and dairy-based beverages); 10% ad valorem tax on drinks with <6.25 g sugar/100 mL.

SSB tax policies implemented in other countries such as the UK and several subnational jurisdictions in the USA have also resulted in statistically significant reductions in SSB purchases. In 2011 Hungary imposed a Public Health Product Tax on food products containing unhealthy levels of sugar, salt and other ingredients, and raised about $68,000) of revenue. In the fourth year, revenue increased to about $100,000 per year. In 2015, it was estimated that the tax had generated the equivalent of $219 million since it went into effect. In Thailand, the United Kingdom, Portugal, Malaysia, and South Africa, the announcement of the imposition of an SSB tax urged manufacturers to reformulate – to reduce the sugar content of their products. Presenting evaluation insights of taxes on SSBs in Mexico, Chile, South Africa, the UK, US, and many other countries, Barry Popkin recently noted that “these taxes impact intake roughly equal to the size of the taxes. Taxes on sugar content and tiered taxes (as in the UK, and South Africa) appear to have a larger effect on both reformulation, and sugar purchases. Volumetric taxes have bigger impact on revenue”.

However, implementation of this policy in Africa is currently sparse (Booth et al 2021; Laar et al 2020). In November 2017, South Africa’s National Assembly passed the Health Promotion Levy – 11% tax applied after the first 4 grams of every 100mL of liquid, and each gram thereafter is taxed at ZAR 2.2 cents per gram. Products covered by the tax when it came into effect in April 2018 included non-alcoholic beer, and to non-alcoholic drinks with added sugar or flavoring in the form of syrups, other concentrates, cocoa powder or malt extract.

In all settings, but more especially in low, and middle income countries, questions of regressivity, elasticity, and equity have been addressed, and answers have been provided. In South Africa for example, Professor Karen Hofman and colleagues reported that academic studies on the policy begun before the implementation of the policy As of April 2021, the studies, as reported by Hofman et al (2021) show the following:

Nationally, prices of taxable carbonated beverages rose whereas non-taxable beverage prices did not change meaningfully (Stacey et al 2019)
Urban household purchases of taxable beverages post implementation fell by 29% with sugar from these purchases falling by 51%. Importantly, lower socioeconomic urban households reduced their volume and grams of sugar from SSBs by 32% and 57%, respectively (Stacey et al 2021)
Daily beverage intake by young (18–39 years) adults showed a 37% reduction in volume and 31% in sugar (Essman et al 2021)
The combined price increase and purchases/sales of SSBs together generated revenues of 5.8 billion ZAR over the first two fiscal years of the tax being in place (approximately 0.2% of total government revenue over the same period) The revenue has gone towards the country’s general fund and was not earmarked, noted Hofman et al (2021)

Other African countries including Mauritius, Seychelles, Morocco, Botswana, and Nigeria have enacted and are implementing SSB tax policies. Implemented April 1, 2019, in Seychelles: $0.22per L import tariff on all beverages containing >5 g sugar/100 mL (exempt: fresh, locally produced drinks without additives and plain milks). Implemented since January 2013, and updated in October 2016, Mauritius imposed $0.00075 per g sugar on sodas, syrups, and fruity drinks with added sugar.

Noted earlier, local economies, but also, the power asymmetries between “public” and “private” interests confound promulgation and implementation of these policies (Laar 2021; Walls et al 2020). Morocco had a very challenging journey. Morocco repealed its SSB tax passed in 2018 prior to implementation – in response to pressures from the agri-food industry. On a second attempt, the Moroccan parliament considered a more watered-down version of the tax ($0.08 per L VAT) on soft and non-carbonated drinks with ≥5 g sugar per 100 mL; $0.07 per L) on energy drinks; $0.02 per L on nectars. But for the concerted advocacy undertaken by civil society and academia, South Africa’s efforts could easily have been thwarted. As Du et al (2018) describe, the tax, which came into effect in April 2018, experienced multiple delays in its implementation since 2016 when it was originally proposed – due to fervent resistance from food companies. The A4H Coalition pays heed.

As Ghana readies to implement the policy in 2023 – as per the Excise Duty Amendment Act, 2022, the question is no longer, can it be done? Or will it be done? It is, how effective will it be? Indeed, we have previously articulated that Ghana’s tax experience shows that it can be done (Rampalli et al 2021). On local evidence, we have over the years generated contextual, fit-for-local purpose to support both the civil society advocacy efforts, as well as provide elucidation to the Ghanaian policymaker of the policy’s rationale and potential impacts. Generating the evidence, we engaged individuals, communities, and local and national stakeholders. The Dietary Transitions in Ghanaian Cities and the ‘MEALS4NCDs Project’ mapped the factors in the social and physical food environments that drive the consumption of energy-dense, nutrient-poor food and beverages. We assessed how unhealthy food and beverages are embedded in everyday life (Holdsworth et al, 2020), and engaged national level stakeholders to identify relevant and potentially feasible public health nutrition policy options for Ghana (Laar et al 2020). We used novel qualitative methods to identify factors shaping dietary behaviors (Pradeilles et al., 2021). We showed how unhealthy food is advertised and sold through geographical mapping studies (Green et al., 2020). Our television monitoring, outdoor food advertising assessment (Amevinya et al 2022), and supermarket assessment (Adjei et al, 2022) The evidence-informed the development of policy recommendations to improve the healthiness of the Ghanaian food environment. Recommendations included the development of policies that account for people’s lived environments and encompass regulatory, legislative, and fiscal measures. But are Ghanaians ready for such? Our community readiness assessments and a recent national poll of about 8,000 Ghanaians helped gauge public support and readiness to accept and implement these policies (Pradeilles et al., 2019; Tandoh et al 2022; Laar et al 2022).

Toward identifying a realistic legal pathway to enact SSB tax in Ghana, the A4H Project commissioned a legal feasibility analysis (Dangbey et al 2022). The analysis concluded that:

There is currently no SSB Tax Law in Ghana, although an excise tax exists for multiple commodities, including SSB.
The existing tax legislations bordering on SSB tax in Ghana, are not robust enough to combat NCDs in Ghana.
The existing laws in Ghana make it legally feasible to adopt an SSB tax in Ghana with the aim of combatting NCDs.
The political will and desire to introduce SSB Tax Law is evident; the government of Ghana (led by the Ministry of Health) has officially initiated the process to develop a bundle of food-based policies (including front-of-pack labelling, marketing regulations, and food-related fiscal policies).

The A4H Project together with the HD4HL Project commissioned several systematic reviews, political economy analysis, corporate political activity assessment, policy coherence analysis, modelling studies, and conducted a nationwide poll to provide policy makers and other stakeholders the needed local evidence. Data from a poll involving a sample of 7,794 residents of Ghana reveal that a significant number (84.3%) were concerned about obesity and NCDs (in adults and children). Two out of three respondents (67.7%) support any effort by the government to impose tax on SSBs or any other food deemed to be bad for health. When respondents were told the money from the taxes could be used to support public health interventions, support for the tax increased to nearly 80% (77.4%).

At the time of writing of this article, the Ghanaian government (the Executive and Legislature) had demonstrated resolve to roll out the tax policy. The Parliament of the Republic of Ghana has just passed the Excise Duty Amendment Bill, 2022. The Excise Duty Act, 2014 (ACT 878) is amended. The amendments include imposition of excise duty (20 per centum of the ex-factory price) on sweetened beverages including fruit juices (e.g. grape and vegetable juices unfermented and containing spirits whether or not containing added sugar of other sweetening matter). Others products covered by the Act are cigarette and tobacco products, wines, malt drinks and spirits, plastics and plastic products etc.

Having come thus far, the Ghanaian government deserves commendation. We encourage and commend the First Gentleman of the land as he gives a Presidential Assent to the Bill. Ghanaians await to be impacted positively by the policy. Ghana should not relent in her bid to promote, protect and guarantee the health of her citizens and residents. The A4H Coalition and other civil society organizations should not, and will not relent in their bid to advocate for the health of Ghana. They will monitor, with keen interest, the implementation of the policy and will demand accountability as needed.

The writer, “Amos Laar, PhD” is a Professor of Public Health Nutrition at the School of Public Health, University of Ghana, Legon and Principal Investigator (PI) of the A4H Project, the HD4HL Project and the ‘MEALS4NCDs Project’ and Co-PI of the Dietary Transitions in Ghanaian Cities. He is a Fellow of the Ghana Academy of Arts and Sciences.