Table 2.

Opportunities and barriers for health taxes

Themes/subthemes	Explanation	Exemplary quotes
Opportunities for health taxes
A supportive environment.	Almost all participants indicated that there was currently a supportive environment for health taxes based on the experience of the current debates on increasing current tobacco taxes and the involvement of strong advocacy groups (such as VALD) and the collaborative efforts of the GRA, Food and Drugs Authority and UNDP. Participants reported regular engagements/meetings between government and advocacy groups on several fronts, including tobacco and alcohol policy, and argued this level of engagement was indicative of a supportive environment. However, some CSOs and global organisations were concerned that the MoF, specifically, may not be fully supportive of this agenda. A review of current taxes on many of these commodities, including tobacco and alcohol, was recommended by global organisations such as the WHO, as the current taxes were perceived to be too low by most stakeholders. Such a review may also aid ongoing debates between different parts of the government (eg, MoH and MoF).	‘The revenue authority guys are in support, the finance ministry was a little bit less enthusiastic, maybe a little more careful, but the revenue guys you know, the revenue collectors, were aware that taxes for spirits were low and tobacco taxes were also low, and they were talking of doing something about it, getting a higher rates, but they were talking about what they want to target, if they should go for cigarettes, or how to get higher rates - so the interest is there’. (Global actor, World Bank)
Health framing (instead of revenue generation).	A health framing of any new taxes (instead of revenue generation) was generally believed to provide an important opportunity for garnering support for new taxes, especially within the context of the current COVID-19 pandemic, which made health issues more salient for many stakeholders. Global and CSO actors also attributed the rising burden of NCDs to increase in consumption of alcohol and SSBs, combined with the impact of COVID-19 on those with NCDs, thus increases salience of the opportunities presented by health taxes.	‘COVID created an opportunity for us. It pointed to us that over 90 percent of the people that died were persons with underlining NCDs and so it is a good reason to us to produce healthy products’. (CSO, revenue mobilisation)
Barriers to health taxes
Political and economic factors.	Despite the sense among many interviewees that there was generally a positive view of health taxes among stakeholders in Ghana (as outlined previously), the industry’s (alcohol and SSBs) role in employment opportunities and their impact on the country’s economy were nonetheless a concern among some interviewees (n=8). The current economic crisis could also present a potential roadblock for any introduction of taxes in the country.	‘We have to realise that some of these taxes are not high enough because of the economic nature of such taxes - for employment opportunities and revenue generation, so sometimes being too hard on them may destroy people’s livelihood, which also makes people angry with the government’. (MoH)
Industry–political links.	The close relationship that the government is perceived to have with the industry was highlighted as an important barrier to implementing any form of health taxes. The tobacco and alcohol industries were regarded as very powerful by stakeholders and have the ability to create jobs and generate revenue. Industry was perceived by many of our interviewees to influence policy by bribing politicians and government officials. A typical example of this (focusing on the tobacco industry) was shared by CSO and journalists.	‘When we say industry, then I know people will have the picture that policymakers are different from the industry players but let me tell you some of these policy makers are in bed with some of these industry operators and some even are sponsored by these players’. (CSO, revenue mobilisation)
Lack of accountability.	About a third of stakeholders identified a perceived lack of government accountability mainly as a result of bribery and corruption. A particular instance cited was the lack of transparency in the management of the new COVID taxes.	‘I think when we had issues with COVID in the country, there was a 1% percentage points set up for COVID, but as at now, I don’t know if there is any accountability, what has been generated or what it has been used for, and all that, because that’s also an earmarked fund of which we know nothing’. (MoH)
Lack of data and evidence.	A third of the stakeholders also argued that there needed to be better local data and evidence on the role of unhealthy commodities in poor health outcomes in Ghana, in order to help make the case health introducing taxes. There was therefore an argument for more publicly accessible research on the health (and economic) impacts of alcohol and SSB consumption in Ghana.	‘We need empirical evidence to inform our bosses. Is there any data to say this number of people died as a result of tobacco or alcohol? But if we just say people are dying without any evidence, it is not helping, and this is something we hear every day’. (MoF)

CSO, civil society organisation; GRA, Ghana Revenue Authortiy; MoF, Ministry of Finance; MoH, Ministry of Health; NCD, non-communicable disease; SSB, sugar-sweetened beverage; UNDP, United Nations Development Programme.