Sugary beverage taxation in South Africa: Household expenditure, demand system elasticities, and policy implications

Trends and ethnic disparity in endometrial cancer mortality in South Africa (1999-2018): A population-based Age-period-cohort and Join point regression analyses

BACKGROUND

Endometrial cancer is the sixth leading cause of cancer among females and about 97,000 global deaths of endometrial cancer. The changes in the trends of obesity, fertility rates and other risk factors in South Africa (SA) may impact the endometrial cancer trends. The aim of this study was to utilise the age period cohort and join point regression modelling to evaluate the national and ethnic trends in endometrial cancer mortality in South Africa over a 20year period (1999-2018).

METHODS

Data from Statistics South Africa was obtained to calculate the annual number of deaths, and annual crude and age standardised mortality rates (ASMR) of endometrial cancer from 1999-2018. The overall and ethnic trends of endometrial cancer mortality was assessed using the Join point regression model, while Age-period-cohort (APC) regression modelling was conducted to estimate the effect of age, calendar period and birth cohort.

RESULTS

During the period 1999-2018, 4,877 deaths were due to endometrial cancer which constituted about 3.6% of breast and gynecological cancer deaths (3.62%, 95% CI: 3.52%-3.72%) in South Africa. The ASMR of endometrial cancer doubled from 0.76 deaths per 100,000 women in 1999 to 1.5 deaths per 100,000 women in 2018, with an average annual rise of 3.6% per annum. (Average Annual Percentage change (AAPC): 3.6%, 95%CI:2.7-4.4, P-value < 0.001). In 2018, the overall mean age at death for endometrial cancer was was 67.40 ± 11.04 years and, the ASMR of endometrial cancer among Indian/Asians (1.69 per 100,000 women), Blacks (1.63 per 100,000 women) and Coloreds (1.39 per 100,000 women) was more than doubled the rates among Whites (0.66 deaths per 100,000 women). Indian/Asians had stable rates while other ethnic groups had increased rates. The Cohort mortality risk ratio (RR) of endometrial cancer increased with successive birth cohort from 1924 to 1963 (RR increased from 0.2 to 1.00), and subsequently declined among successive cohorts from 1963 to 1998 (1.00 to 0.09). There was strong age and cohort but not period effect among the South African women. Ethnic disparity showed that there was age effect among all the ethnic groups; Cohort effect among Blacks and Coloureds only, while Period effect occurred only among Blacks.

CONCLUSIONS

The mortality rates of endometrial cancer doubled over a twenty-year period in South Africa from 1999-2018. There was strong ethnic disparity, with age and cohort effect on endometrial cancer trends. Thus, targeted efforts geared towards prevention and prompt treatment of endometrial cancer among the high-risk groups should be pursued by stake holders.

Modelling the potential impact of a tax on fruit juice in South Africa: implications for the primary prevention of type 2 diabetes and health financing

BACKGROUND

South Africa is experiencing a persistent growth in non-communicable diseases. Diabetes is among the top ten causes of mortality, especially among women, which is partly driven by high levels of added sugar consumption and obesity. To reduce obesity rates and the incidence of diabetes, South Africa introduced a tax on sugar sweetened beverages (also known as the Health Promotion Levy (HPL)) in 2018. The tax is applicable to sugar-sweetened beverages but excludes 100% fruit juice. The government is currently considering extending the tax to include fruit juices. This study models the potential health and economic impact of taxing fruit juices at 20% of the retail price of one liter.

METHODS

To analyze the distributional impact of the tax, this study uses extended cost-effectiveness analysis methodology. Data on price elasticities, healthcare cost, income, fruit juice consumption were sourced from the literature and representative national surveys. The potential impact of the tax on diabetes incidence, prevalence, mortality, and financial benefits were estimated for each income group (lowest, quintile 1 to highest, quintile 5).

FINDINGS

We estimate that a 20% tax on fruit juice would avert 156,640 incident cases of type 2 diabetes mellitus over 20 years, with most disease averted occurring among the first- and fifth-income groups. Averted deaths from diabetes would average 2,000 deaths per quintile (for quintiles 1 to 4) and about 2,800 in quintile 5. The improved health resulting from averted incidence and deaths will reduce overall healthcare expenditure by R7.5 billion over 20 years, of which R2.3 billion will occur in the fifth quintile. The South African government will also save about R300 million in subsidizing diabetes-related healthcare cost as a result of prevention; and would raise R8.6 billion in tax revenues per annum. Out-of-pocket expenditure savings will be R303 million and a financial risk protection (money-metric value of insurance) of R4.6 billion over the 20-year period.

CONCLUSION

We conclude that an HPL that significantly raises the retail price of fruit juices would reduce consumption and diabetes-related morbidity and mortality. The tax will also provide significant financial benefits in the form of reduced healthcare costs for both government and households as well as providing financial risk protection to individuals. Health taxes are win-win policies that improve population health and generate revenue for governments to fund public health services delivery and thus improve overall health financing activities of the government. Therefore, population level disease prevention measures such as health taxes are important for achieving universal health coverage.

Mapping of food environment policies in Zambia: a qualitative document analysis

BACKGROUND

The food environment in which people exercise food choices significantly impacts their dietary patterns. Policies that limit the availability, affordability, and access to unhealthy food while increasing that of healthier alternatives help build healthy food environments, which are required to address the double burden of malnutrition. This study aimed to assess the availability of food environment policies in Zambia.

METHOD

We applied a two-step qualitative document analysis to identify policy content relating to healthy food environments from global and Zambia-specific nutrition-related policy documents. In the first step, global policy documents were analyzed to develop a reference point for globally recommended policies for healthy food environments. In the second step, Zambia's nutrition-related policies were analyzed to identify content relating to healthy food environments. The identified policy content was then mapped against the global reference point to identify food environment policy gaps.

RESULTS

Our analysis of global policy recommendations identified five broad categories of policy provisions: information and education based; regulatory and legislative tools; strategies to promote production and access to healthy food production; social protection-based strategies and guiding principles for governments relating to multisectoral collaboration and governance. Our analysis found that Zambian Government policy documents in the health, agriculture, education, and national planning and development sectors have policy provisions for healthy food environments. While these policy provisions generally covered all five reference categories, we found policy gaps in the regulatory and legislative tools category relative to global recommendations.

CONCLUSION

Zambia's food environment policy landscape must include globally recommended regulatory and legislative policy measures like restricting the marketing of unhealthy foods and non-alcoholic beverages to children. Nutrition policy reforms are required to facilitate the introduction of regulatory and legislative policy measures that effectively address the double burden of malnutrition in Zambia.

Effect of price and income on the demand for sugar-sweetened beverages in Nigeria: an analysis of household consumption data using an almost ideal demand system (AIDS)

OBJECTIVES

To estimate the own-price, cross-price and income elasticities for carbonated soft drinks (CSDs), malt drinks, chocolate powder, sachet water and sugar in Nigeria. These elasticities can be used to estimate the potential demand response to the recently-introduced sugar tax in Nigeria.

SETTING

The study uses household data from the 2018/2019 Nigeria Living Standards Survey (NLSS).

PARTICIPANTS

The NLSS is a national household survey. 21 114 households were included in the final sample for this analysis.

PRIMARY AND SECONDARY OUTCOMES

We used Deaton's almost ideal demand system, which controls for the goods' quality, to estimate the effect of price and income changes on the demand for CSDs, chocolate powder, malt drinks, sachet water and sugar.

RESULTS

We found that the own-price elasticity (ordered from most to least price-responsive) was -0.99 (p<0.01) for sachet water, -0.76 (p<0.01) for CSDs, -0.72 (p<0.01) for chocolate powder, -0.62 (p<0.01) for sugar and -0.19 (p<0.01) for malt drinks. The cross-price elasticities indicate that malt drinks and chocolate powders are substitutes of CSDs. The income elasticities indicate that all the commodities are normal goods. Sachet water had the highest income elasticity at 0.62 (p<0.01), followed by chocolate powder at 0.54 (p<0.01), CSDs at 0.47 (p<0.01), malt drinks at 0.43 (p<0.01) and sugar at 0.13 (p<0.01).

CONCLUSION

Even though the price elasticities for CSDs, malt drinks and chocolate powder are less than one, in absolute terms, they are significantly different from zero. Increases in the sugar-sweetened beverage tax could curb the demand for these beverages, and, in turn, reduce the incidence and prevalence of sugar-attributable diseases.

Changes in beverage purchases following the announcement and implementation of South Africa's Health Promotion Levy: an observational study

BACKGROUND

In 2016, South Africa announced an intention to levy a tax on sugar-sweetened beverages (SSBs). In 2018, the country implemented an SSB tax of approximately 10%, known as the Health Promotion Levy (HPL). We aimed to assess changes in the purchases of beverages before and after the HPL announcement and implementation.

METHODS

We used Kantar Europanel data on monthly household purchases between January, 2014, and March, 2019, among a sample of South African households (n=113 653 household-month observations) from all nine provinces to obtain per-capita sugar, calories, and volume from taxable and non-taxable beverages purchased before and after the HPL announcement and implementation. We describe survey-weighted means for each period, and regression-controlled predictions of outcomes and counterfactuals based on pre-HPL announcement trends, with bootstrapped 95% CIs, and stratify results by socioeconomic status.

FINDINGS

Mean sugar from taxable beverage purchases fell from 16·25 g/capita per day (95% CI 15·80-16·70) to 14·26 (13·85-14·67) from the pre-HPL announcement to post-announcement period, and then to 10·63 g/capita per day (10·22-11·04) in the year after implementation. Mean volumes of taxable beverage purchases fell from 518·99 mL/capita per day (506·90-531·08) to 492·16 (481·28-503·04) from pre-announcement to post announcement, and then to 443·39 mL/capita per day (430·10-456·56) after implementation. Across these time periods, there was a small increase in the purchases of non-taxable beverages, from 283·45 mL/capita per day (273·34-293·56) pre-announcement to 312·94 (296·29-329·29) post implementation. When compared with pre-announcement counterfactual trends, reductions in taxable beverage purchase outcomes were significantly larger than the unadjusted survey-weighted observed reductions. Households with lower socioeconomic status purchased larger amounts of taxable beverages in the pre-announcement period than did households with higher socioeconomic status, but demonstrated bigger reductions after the tax was implemented.

INTERPRETATION

The announcement and introduction of South Africa's HPL were followed by reductions in the sugar, calories, and volume of beverage purchases.

FUNDING

Bloomberg Philanthropies, International Development Research Centre, South African Medical Research Council, and the US National Institutes of Health.

Consumers' Motives for Eating and Choosing Sweet Baked Products: A Cross-Cultural Segmentation Study

This study aimed to examine consumers' motives for eating and choosing sweet baked products (SBPs). A cross-cultural segmentation study on a South African (SA) and Swiss population sample (n = 216), was implemented using the Motivation for Eating Scale (MFES) and the Food Choice Questionnaire (FCQ). Cluster analyses provided three consumer segments for each population sample: the balanced and the frequenters for both countries, the deniers for SA, and the health conscious for Switzerland. South Africans liked SBPs more than the Swiss respondents, however the Swiss sample consumed SBPs more often. Environmental and physical eating were the most relevant motives when eating SBPs for the SA and Swiss group, respectively. For both samples, sensory appeal was the deciding factor when choosing SBPs. Cross-cultural studies of food choices are important tools that could help improve the current understanding of factors that influence the eating behavior of ultra-processed foods to promote healthy food choices through local and global perspectives. This paper highlights that more research is needed on consumers' motives for choosing and eating ultra-processed foods in order to develop specific integrative cultural exchange actions or intervention strategies to solve the obesity issue.

The distributional impact of taxing sugar-sweetened beverages: findings from an extended cost-effectiveness analysis in South Africa

BACKGROUND

Facing increasing obesity prevalence and obesity-related disease burden, South Africa has devised an obesity prevention strategy that includes a recently implemented tax on the sugar content of sugar-sweetened beverages (SSB). We assess the potential distributional impact (across socioeconomic groups) of this tax on type 2 diabetes mellitus (T2DM) incidence and associated mortality and its financial burden on households.

METHODS

We conducted an extended cost-effectiveness analysis of the new 10% tax on SSBs in South Africa, and estimated: the averted premature deaths related to T2DM, the financial benefits to households (out-of-pocket (OOP) medical costs and indirect costs due to productivity losses averted), the increased government tax revenues and healthcare savings for the government, all across income quintiles.

FINDINGS

A 10% SSB tax increase would avert an estimated 8000 T2DM-related premature deaths over 20 years, with most deaths averted among the third and fourth income quintiles. The government would save about South African rand (ZAR) 2 billion (US$140 million) in subsidised healthcare over 20 years; and would raise ZAR6 billion (US$450 million) in tax revenues per annum. The bottom two quintiles would bear the smallest tax burden increase (36% of the additional taxes). The bottom two income quintiles would also have the lowest savings in OOP payments due to significant subsidisation provided by government healthcare. Lastly, an estimated 32 000 T2DM-related cases of catastrophic expenditures and 12 000 cases of poverty would be averted.

CONCLUSIONS

SSB taxation would have a substantial distributional impact on obesity-related premature deaths, cost savings to the government and the financial outcomes of South Africa's population.

Sugar-based beverage taxes and beverage prices: Evidence from South Africa's Health Promotion Levy

A growing number of jurisdictions are introducing taxes on sugar-sweetened beverages (SSBs) in efforts to reduce sugar intake, obesity, and associated metabolic conditions. A key dimension of the impact of such taxes is how they induce changes in the prices of the taxed beverages and their un-taxed substitutes. At present these taxes have typically been based solely on volume. More recently, however, due to the potential to target the source of SSBs' health harms and to incentivize product reformulation, SSB taxes are being levied based on sugar content. In April of 2018 South Africa implemented such a tax, the Health Promotion Levy (HPL), at a rate of 0.021 ZAR (approximately 0.15 US cents) for each gram of sugar over an initial threshold of 4 g/100 ml. Drawing on a dataset of price observations (N = 71, 677) collected in South Africa between January 2013 and March 2019, we study changes in beverage prices following the introduction of the HPL. We find null price increases among un-taxed beverages and find significant price increases for carbonates, the largest taxed product category. However, within carbonates we find similar increases in price for low- and high-sugar brands, despite the underlying difference in tax liability. In addition, while we find evidence of product reformulation, we find significant price increases among the brands that reduced their sugar content. While the findings are broadly consistent with the price changes of volume-based SSB taxes, future considerations of price effects of sugar-based SSB taxes need to account for the opportunity for intra-firm heterogeneity in price response among large multi-product firms.

Taxing highly processed foods: What could be the impacts on obesity and underweight in sub-Saharan Africa?

The consumption of highly processed food has been singled out as one of the factors responsible for the rapidly increasing prevalence of obesity and its associated non-communicable diseases and costs. While obesity prevalence is still comparatively low in lower-income sub-Saharan Africa (SSA), development prospects in this region render markets especially attractive for these foods, whose consumption is already growing at higher rates than in developed countries. This might be reflected in the massive rise in obesity prevalence growth rates in SSA over the past decade, while many of these countries are simultaneously struggling with high undernutrition prevalence. Using a newly constructed cross-country panel dataset, this study econometrically investigates the effect of higher import tariffs on highly processed vis-à-vis less-processed foods with respect to their impacts on obesity and underweight prevalence in the adult population. While the analysis is global, the discussion focuses primarily on SSA. The effects of the tariff differences are found to be significant and substantial and to differ by income level of the country as well as by gender. More generally, the results show that policies affecting the consumer price differential between the two food groups are effective in influencing obesity and underweight prevalence and that these two issues cannot be treated separately.

Sugar and energy content of carbonated sugar-sweetened beverages in Haidian District, Beijing: a cross-sectional study

OBJECTIVE

The consumption of carbonated sugar-sweetened beverages (CSSBs) is associated with a range of health problems, but little is known about the sugar and energy content of CSSBs in China. The study aimed to investigate the sugar and energy content of CSSBs in Beijing, China.

STUDY DESIGN

We carried out a cross-sectional survey in 15 different supermarkets from July to October 2017 in Haidian District, Beijing.

METHODS

The product packaging and nutrient labels of CSSBs were recorded by a snapshot in time to obtain company name, product name, serving size, and nutrient content, that is, carbohydrate, sugar and energy. For CSSB labels not showing sugar content, we used carbohydrate content as substitute. The sugar and energy content of CSSBs within each type of flavour were compared using Kruskal-Wallis test. The sugar content within the recommended levels was described using frequency. We also compared the sugar and energy content of top 5 CSSBs in terms of sales among three countries (China, UK and USA).

RESULTS

A total of 93 CSSB products were found. The median sugar content was 9.3 (IQR: 5.7-11.2) g/100 mL, and the energy content was 38 (IQR: 23-46) kcal/100 mL. There were 79 products labelled 'Red' (high) per serving based on the criteria set in the UK (>11.25 g/100 mL). We found 62.4% of CSSBs had sugar content per serving that exceeds the daily free sugar intake for adults (25 g) recommended by the WHO. Some of the branded products sold in China had higher sugar content when they were compared with those in Western countries.

CONCLUSIONS

CSSBs in Beijing, China have high sugar and energy content. Reduction in sugar content and serving size of CSSBs and taxation policy on beverages will be beneficial in reducing sugar intake in China.

Simulating the impact of excise taxation for disease prevention in low-income and middle-income countries: an application to South Africa

Introduction

Excise taxes are policy tools that have been applied internationally with some success to reduce consumption of products adversely impacting population health including tobacco, alcohol and increasingly junk foods and sugary beverages. As in other low-income and middle-income countries, South Africa faces a growing burden of lifestyle diseases; accordingly we simulate the impact of multiple excise tax interventions in this setting.

Methods

We construct a mathematical model to simulate the health and revenue effects of increased excise taxes, which is adaptable to a variety of settings given its limited data requirements. Applying the model to South Africa, we simulate the impact of increased tax rates on tobacco and beer and of the introduction of a tax on sugar-sweetened beverages (SSB). Drawing on surveys of product usage and risk factor prevalence, the model uses a potential impact fraction to simulate the health effects of tax interventions.

Results

Adopting an excise rate of 60% on tobacco would result in a gain of 858 923 life-years (95% uncertainty interval (UI) 480 188 to 1 310 329), while adopting an excise rate of 25% on beer would result in a gain of 568 063 life-years (95% UI 412 110 to 775 560) and the adoption of a 20% tax on SSBs would result in a gain of 688 719 life-years (95% UI 321 788 to 1 079 653).

Conclusion

More aggressive excise tax policies on tobacco, beer and SSBs in South Africa could result in meaningful improvements in population health and raised revenue.