The legal feasibility of adopting a sugar-sweetened beverage tax in seven sub-Saharan African countries.

Background: A number of countries have adopted sugar-sweetened beverage taxes to prevent non-communicable diseases but there is variance in the structures and rates of the taxes. As interventions, sugar-sweetened beverage taxes could be cost-effective but must be compliant with existing legal and taxation systems.Objectives: To assess the legal feasibility of introducing or strengthening taxation laws related to sugar-sweetened beverages, for prevention of non-communicable diseases in seven countries: Botswana, Kenya, Namibia, Rwanda, Tanzania, Uganda and Zambia.Methods: We assessed the legal feasibility of adopting four types of sugar-sweetened beverage tax formulations in each of the seven countries, using the novel FELIP framework. We conducted a desk-based review of the legal system related to sugar-sweetened beverage taxation and assessed the barriers to, and facilitators and legal feasibility of, introducing each of the selected formulations by considering the existing laws, laws related to impacted sectors, legal infrastructure, and processes involved in adopting laws.Results: Six countries had legal mandates to prevent non-communicable diseases and protect the health of citizens. As of 2019, all countries had excise tax legislation. Five countries levied excise taxes on all soft drinks, but most did not exclusively target sugar-sweetened beverages, and taxation rates were well below the World Health Organization's recommended 20%. In Uganda and Kenya, agricultural or HIV-related levies offered alternative mechanisms to disincentivise consumption of sugar-sweetened beverages without the introduction of new taxes. Nutrition-labelling laws in all countries made it feasible to adopt taxes linked to the sugar content of beverages, but there were lacunas in existing infrastructure for more sophisticated taxation structures.Conclusion: Sugar-sweetened beverage taxes are legally feasible in all seven countries Existing laws provide a means to implement taxes as a public health intervention.

The data availability landscape in seven sub-Saharan African countries and its role in strengthening sugar-sweetened beverage taxation.

Background: Credible data and indicators are necessary for country-specific evidence to support the design, implementation, monitoring and evaluation of sugar-sweetened beverage (SSB) taxation.Objective: A cross-country analysis was undertaken in seven Sub-Saharan African countries to describe the potential role of available data in strengthening SSB taxation. The objectives were to: document currently available data sources; report on public access; discuss strengths and limitations for use in monitoring SSB taxation; describe policy maker's data needs, and propose improvements in data collection.Methods: The study used a mixed-methods approach involving a secondary data analysis of publicly available documents, and a qualitative exploration of the data needs of policy makers' using primary data. Findings were synthesised and assessed for data strengths and weaknesses, including usability and availability. SSB taxation-related data availability was critically assessed with respect to adequacy in strengthening taxation policy on SSBs.Results: Findings showed a paucity of SSB taxation-related data in all seven countries. National survey data are inadequate regarding the intake of SSBs and household expenditure on SSBs. Fiscal data from SSB tax revenue, value added tax from SSB sales, corporate income tax from SSB companies and SSB custom duty revenues, are lacking. Accurate information on the soft drink industry is not easily accessed.Conclusion: Timely, easily understood, concise, and locally relevant evidence is needed in order to inform policy development on SSBs. The relevant data are drawn from multiple sectors. Cross- sector collaboration is therefore needed. Indicators for SSBs should be developed and included in current data collection tools to ensure monitoring and evaluation for SSB taxation.

Strengthening prevention of nutrition-related non-communicable diseases through sugar-sweetened beverages tax in Rwanda: a policy landscape analysis.

Background: Food and beverages high in sugar are recognized to be among the major risk factors for nutrition-related non-communicable diseases. The growing presence of ultra-processed food producers has resulted in shifts to diets that are associated with non-communicable diseases and which include sugar-sweetened beverages. Sugar-sweetened beverage taxation presents an opportunity to prevent non-communicable diseases but it comes with challenges.Objectives: To describe the policy landscape, identify and analyse the facilitators of and barriers to strengthening taxation on sugar-sweetened beverages in Rwanda.Methods: We conducted a desk-based policy analysis to assess the facilitators of and barriers to strengthening sugary beverage taxation policy. We consulted eight stakeholders to validate the findings of the desk review.Results: Non-communicable diseases are recognized as a public health challenge in Government health and non-health policy documents. However, sugar intake is not explicitly identified as a risk factor for non-communicable diseases and existing policies do not clearly aim to reduce sugar consumption. The Rwandan Government's commitment to growing the local sugar industry and the substantial economic contribution of Rwandan beverage producers are potential barriers to fiscal policies aimed at reducing sugar consumption. However, the current 39% excise tax levied on all soft drinks could support the adoption of future sugar-sweetened beverage policies.Conclusions: The landscape for strengthening a sugar-sweetened beverage tax in Rwanda is complex. The policy environment provides both facilitators of and impediments to strengthening the existing tax. A differential tax could be introduced by leveraging on the existing excise tax and linking it to the sugar content of beverages.

The political economy of sugar-sweetened beverage taxation: an analysis from seven countries in sub-Saharan Africa.

Background: Non-communicable diseases are on the rise across sub-Saharan Africa. The region has become a targeted growth market for sugar-sweetened beverages, which are associated with weight gain, cardiovascular diseases and diabetes.Objective: To identify politico-economic factors relevant to nutrition-related fiscal policies, and to draw lessons regarding strategies to strengthen sugar-sweetened beverages taxation in the region and globally.Methods: We collected documentary data on policy content, stakeholders and corporate political activity from seven countries in east and southern Africa augmented by qualitative interviews in Botswana, Namibia, Kenya and Zambia, and stakeholder consultations in Rwanda, Tanzania and Uganda. Data were analysed using a political economy framework, focusing on ideas, institutions, interests and power, and a 'bricolage' approach was employed to identify strategies for future action.Results: Non-communicable diseases were recognised as a priority in all countries. Kenya, Zambia, Rwanda, Tanzania and Uganda had taxes on non-alcoholic beverages, which varied in rate and tax base, but appeared to be motivated by revenue rather than health concerns. Botswana and Namibia indicated intention to adopt sugar-sweetened beverage taxes. Health-oriented sugar-sweetened beverage taxation faced challenges from entrenched economic policy paradigms for industry-led economic growth and was actively opposed by sugar-sweetened beverage-related industries. Strategies identified to support stronger sugar-sweetened beverage taxation included shifting the economic discourse to strengthen health considerations, developing positive public opinion, forging links with the agriculture sector for shared benefit, and leadership by a central government agency.Conclusions: There are opportunities for more strategic public health engagement with the economic sector to foster strong nutrition-related fiscal policy for non-communicable disease prevention in the region.

Study design: policy landscape analysis for sugar-sweetened beverage taxation in seven sub-Saharan African countries.

This paper reports on the design of a study to examine the policy landscape relevant to sugar-sweetened beverage taxation in seven sub-Saharan African countries. The study responds to the need for strong policy to address the rising burden of non-communicable diseases in the region. Sugar-sweetened beverage taxation has been widely recommended as a key component of a comprehensive policy approach to NCD prevention. However, it has proved a contentious policy intervention, with industry strongly opposing the introduction of such taxes. The aim was to identify opportunities to strengthen sugar-sweetened beverage taxation-related policy for the prevention of nutrition-related NCDs in a subset of Eastern and Southern African countries: Kenya, Tanzania, Botswana, Rwanda, Namibia, Zambia, Uganda. The study was conducted as a collaboration by researchers from nine institutions; including the seven study countries, South Africa, and Australia. The research protocol was collaboratively developed, drawing on theories of the policy process to examine the existing availability of evidence, policy context, and stakeholder interests and influence. This paper describes the development of a method for a policy landscape analysis to strengthen policies relevant to NCD prevention, and specifically sugar-sweetened beverage taxation. This takes the form of a prospective policy analysis, based on systematic documentary analysis supplemented by consultations with policy actors, that is feasible in low-resource settings. Data were collected from policy documents, government and industry reports, survey documentation, webpages, and academic literature. Consultations were conducted to verify the completeness of the policy-relevant data collection. We analysed the frames and beliefs regarding the policy 'problems', the existing policy context and understandings of sugar-sweetened beverage taxation as a potential policy intervention, and the political context across relevant sectors, including industry interests and influence in the policy process. This study design will provide insights to inform public health action to support sugar-sweetened beverage taxation in the region.

Closing the Poor-Rich Gap in Contraceptive Use in Rwanda: Understanding the Underlying Mechanisms.

CONTEXT: Evidence suggests that as Rwanda has strengthened its family planning program, disparities in contraceptive use by socioeconomic status have narrowed. However, the changes in these gaps, and the mechanisms that underlie them, are not well understood. METHODS: Data from the 2005, 2010 and 2015 Rwanda Demographic and Health Surveys on 19,028 in-union women aged 15-49 were analyzed to examine trends in socioeconomic disparities in contraceptive use. Descriptive statistics and multivariate regression with interaction terms were used to identify changes in these disparities, as well as to describe trends in desired fertility, and in types and sources of contraceptives used. RESULTS: Between 2005 and 2015, the prevalence of modern contraceptive use rose from 11% to 48%. In the regression analysis, interaction terms indicated that prevalence increased to a lesser extent among women who were wealthy, had a least a secondary education or lived in urban areas than among those who were poor, were uneducated or lived in rural areas (odds ratios, 0.5-0.7). In parallel, declines in desired fertility were greater among women with no education than among those with at least a secondary education (by 0.7 vs. 0.5 children); among the poorest than the richest women (by 1.0 vs. 0.5 children); and among rural than urban residents (by 0.9 vs. 0.4 children). CONCLUSIONS: The shrinking of gaps in contraceptive use by socioeconomic status coincided with narrowing of disparities in demand for children and with improvements in family planning services, suggesting that disadvantaged populations may have especially benefited from public programs to increase contraceptive access.

RESUMEN Contexto: La evidencia sugiere que a medida que Ruanda ha fortalecido su programa de planificación familiar, las disparidades en el uso de anticonceptivos con base en el nivel socioeconómico se han reducido. Sin embargo, los cambios en estas brechas y los mecanismos subyacentes no son bien comprendidos. Métodos: Se analizaron datos de las Encuestas Demográficas y de Salud de Ruanda de 2005, 2010 y 2015 correspondientes a 19,028 mujeres de 15 a 49 años que vivían en unión libre, con el fin de examinar las tendencias en las disparidades socioeconómicas en el uso de anticonceptivos. Se utilizaron estadísticas descriptivas y regresión multivariada con términos de interacción para identificar cambios en estas disparidades, así como para describir tendencias en la fecundidad deseada y los tipos y fuentes de anticonceptivos utilizados. Resultados: Entre los años 2005 y 2015, la prevalencia del uso de anticonceptivos modernos aumentó del 11% al 48%. En los análisis de regresión, los términos de interacción indicaron que la prevalencia aumentó en menor medida entre las mujeres con buena posición económica, que tenían al menos educación secundaria o que vivían en áreas urbanas en comparación con las que vivían en condiciones de pobreza, carecían de escolaridad o vivían en áreas rurales (razón de probabilidades, 0.5­0.7). Paralelamente, los descensos en la fecundidad deseada fueron mayores entre las mujeres sin escolaridad que entre aquellas con al menos educación secundaria (en 0.7 vs. 0.5 hijos); entre las mujeres con mayor pobreza que las de mayor riqueza (por 1.0 vs. 0.5 hijos); y entre residentes rurales en comparación con las residentes urbanas (por 0.9 vs. 0.4 hijos). Conclusiones: La reducción de las brechas en el uso de anticonceptivos por el nivel socioeconómico coincidió con la reducción de las disparidades en la demanda de hijos y con mejoras en los servicios de planifcación familiar, lo que sugiere que las poblaciones desfavorecidas podrían haberse beneficiado especialmente de los programas públicos para aumentar el acceso a los anticonceptivos.

RÉSUMÉ Contexte: Les données laissent entendre, à mesure du renforcement du programme de planification familiale au Rwanda, un rétrécissement des écarts de la pratique contraceptive suivant la situation socioéconomique. L'évolution de ces disparités, et les mécanismes qui la sous-tendent, ne sont cependant pas bien compris. Méthodes: Les données des Enquêtes démographiques et de santé 2005, 2010 et 2015 du Rwanda concernant 19.028 femmes en union âgées de 15 à 49 ans ont été analysées pour examiner les tendances des disparités socioéconomiques sur le plan de la pratique contraceptive. L'évolution de ces disparités, de même que les tendances concernant la fécondité désirée et les types et sources de contraceptifs utilisés, ont été identifiés et décrits par statistiques descriptives et régression multivariée avec termes d'interaction. Résultats: Entre 2005 et 2015, la prévalence de la contraception moderne est passée de 11% à 48%. Dans les analyses de régression, les termes d'interaction indiquent une hausse moindre de cette prévalence parmi les femmes riches, instruites au niveau pour le moins secondaire ou vivant en milieu urbain, par rapport à leurs homologues pauvres, non instruites ou résidentes des milieux ruraux (RC, 0,5­0,7). Parallèlement, la baisse de la fécondité désirée s'est avérée plus importante parmi les femmes non instruites par rapport à celles dotées d'une éducation de niveau au moins secondaire (dans une mesure de 0,7 vs 0,5 enfant); parmi les femmes les plus pauvres par rapport aux plus riches (1,0 vs 0,5) et parmi les résidentes des milieux ruraux par rapport aux milieux urbains (0,9 vs 0,4). Conclusions: L'amoindrissement des écarts de la pratique contraceptive en fonction de la situation socioéconomique coïncide avec celui des disparités du désir de fécondité et avec l'amélioration des services de planification familiale, laissant entendre que les populations défavorisées peuvent avoir particulièrement bénéficié des programmes publics d'élargissement de l'accès à la contraception.