Economic priorities over population health: A political dilemma in addressing noncommunicable diseases in developing countries

Abstract

The world is observing a rapid shift in the burden of diseases with predominance of noncommunicable diseases (NCDs). NCDs contribute to 41 million deaths which is equivalent to 74% of all death globally per year. There is ongoing debate on the approaches to reduce public exposure to NCDs' modifiable risk factors which are of economic potential. As the World Health Organization and the World Bank recommend the implementation of taxation to these factors, still questions arise on the effectiveness, sustainability, and practicality of this strategy. With the ongoing transition globally from consumption of natural to processed foods, it is important to counter‐check the best interventions on how to protect people from unhealthy eating behaviors. While taxation on unhealthy food and other products like tobacco has been recommended as one among interventional approaches, its effectiveness on sugar sweetened beverages is not reliable compared to approaches that increase self‐control. Despite the perceived economic benefits of tobacco and sugar sweetened products, there is detrimental implication in terms of public health. The introduction of taxation which favors public health faces challenges due to conflict of interest from government authorities and other stakeholders. The intertwined relationship between public health and economic development becomes more obvious during implementation of preventive and control measures against modifiable risk factors for NCDs. It is evident that reaching a balanced rational decision on choosing between economic growth and public health is difficult. Countries should enhance both local and international intersectoral and multisectoral approaches in creating integrative policies which include health component in all non‐health policies including economic policies so as to harmonize public health and economic growth during this era of extensive globalization.

1. INTRODUCTION

The world is observing a rapid shift in the burden of diseases with a transition from communicable diseases to noncommunicable diseases (NCDs). ¹ , ² These diseases include cancer, cardiovascular diseases, chronic respiratory diseases, and diabetes as the commonest NCDs. NCDs contribute up to 41 million deaths which is equivalent to 74% of all death globally per year, with cardiovascular diseases leading with the highest proportion resulting into death. Increasing mortality is expected to occur if the situation is not counter checked. ³ Unfortunately, both health and non‐health policies including economic policies have direct or indirect influence to the public health and their interdependency is inevitable. ⁴ , ⁵ The economic implications of NCDs are evident and have disproportional distribution according to the economic status and type of disease. ⁶ The chronic character of NCDs cause catastrophic expenditure to patients and their families in the course of seeking care and managing their respective complications. ⁶ , ⁷ , ⁸ While the number might be very low in developing countries, the World Bank estimated that by 2018, almost half the world lived on less than 5.5 USD while the cost for NCDs treatment in low and middle income countries was found to range between 1017.05 and 7386.81 USD. ⁷ , ⁹ In India, the mean expenditure for out of pocket treatment cost in public hospitals by households with NCDs was found to be INR 13,170 which was more than twice when compared to non‐NCDs' households. ⁶

There is ongoing debate on the approaches to reduce the public exposure from modifiable risk factors which are of economic potential. These include discouraging the use of tobacco products and sugar sweetened beverages (SSB) like carbonated drinks which are from industries with a significant contribution to the gross domestic product of countries and employment opportunities while at the same time costing the health of consumers. ¹⁰ , ¹¹ , ¹² As the World Health Organization and the World Bank recommend the implementation of taxation so as to increase the cost and discourage purchases among consumers, questions arise on the effectiveness, sustainability, and practicality of this recommendation to bring best results. ¹³ , ¹⁴ , ¹⁵ , ¹⁶ , ¹⁷

This article highlights the global political dilemma faced by countries, especially in low and middle income regions, in addressing the rapidly increasing burden of NCDs. It involves dilemmas that respective countries encounter in the implementation of different recommendations with economic implications in curbing the burden of NCDs.

2. NCDS RISK FACTORS

NCDs cause devastating effects on both human health, healthcare expenditure, house hold expenditure, and national expenditure on health services. ³ , ⁶ , ⁸ Most NCDs share risk factors, which can either be modifiable or non‐modifiable. ¹⁸ Example of non‐modifiable risk factors are age, sex, ethnicity, and genetic factors whereas modifiable risk factors are diet, exercise, use of tobacco, and alcohol. ¹⁸ There is a disproportional risk of developing NCDs depending on socioeconomic status, immune system, occupation, physical activity, and age. ¹⁹ , ²⁰ , ²¹ , ²² , ²³ Among the aggravating factors for increased susceptibility are urbanization and transition in nutritional behaviors and the cooccurrence of multiple risk factors. ¹⁹ , ²¹ , ²⁴ , ²⁵ As the food processing industry is growing in developing countries like in Africa, the use of foods with low nutritional value is likely to increase too. With the ongoing nutritional transition from consumption of natural to ultra‐ processed food with low nutritional value, it is important counter‐check means of protecting people from unhealthy eating behaviors. ²⁶ Despite the current efforts in controlling the tobacco industry, such efforts are challenged by socioeconomic and political factors. ²⁷ , ²⁸ , ²⁹ , ³⁰

3. ECONOMIC PRIORITIES OVER POPULATION HEALTH

The use of tobacco and SSB are products that predominate the debate on economic gain over public health. There has been an increase in production, demand, and use of these products that vary according to geographical regions. In East and Central Africa, the demand of SSB is progressively increasing and more companies are attracted to invest in the region. Some governments have set policies to enhance industry growth, set tax, and levies for these products with expectations to increase the national income. ³¹

The tobacco industry has been the back‐bone of some countries' economy in terms of employment and country's source of foreign currencies. These countries fail to control the tobacco industry despite knowing the adverse effects it cause on human health and environment. ²⁷ While taxation has been used to discourage the use of tobacco products and SSB, this approach is not as effective as compared to approaches that increase self‐control. ¹⁸ , ³² , ³³ Some studies show that the public is in favor of such an approach and it can be effective in discouraging the use of such unhealthy products of NCDs concern. ³⁴ , ³⁵ In South Africa where the government introduced the health promotion levy and a tax imposed on sugar to increase purchasing cost of SSB and discourage consumption, still citizens did not significantly reduce their demands. The study identified low awareness on the motives of the levy, and were influenced by addiction and branding effect to purchase SSB. ³⁶ , ³⁷ Moreover, implementation of taxation in sugar based on sugar content might counteract this effect. ³⁸

The introduction of taxation that can have a positive effect on the public health faces challenges due to the conflict of interest from government authorities and different globalization stakeholders. ³⁹ , ⁴⁰ This is mainly due to lack of common understanding or agreement of the purpose or goal of taxation imposed to these products. Ultimately, when users develop NCDs they suffer long term direct and indirect health cost, increased absenteeism on work, and reduced ability to work. In the Latin America, more than 10% of death were caused by smoking and costing 26.9 United States dollar as direct health cost. ⁴¹ Dental diseases to children, obesity and diabetes due to sugar‐sweetened drinks and significant levels of absenteeism in Gulf countries occurred as a result of NCD illness. ¹¹ , ⁴²

Despite the perceived economic benefits of tobacco and sugar sweetened products, implications on public health is of detrimental outcomes. If the increase in prevalence of NCDs is not controlled, countries will have to suffer both increased burden of NCDs and respective negative economic development as they have been reported in some countries including Fiji. ⁸ , ⁴³ Furthermore, in developing countries like those in Africa, despite the economic benefits such job creation and contribution to national GDP offered by rapidly growing processed food industries, there has been increasing burden of NCDs cases as the consequence. ⁴⁴ , ⁴⁵

It is evident that reaching rational decision in choosing between economic growth and population health is difficult. Any efforts to reduce one‐third of premature death caused by NCDs at one point interferes with the achievement of measures to alleviate poverty and promote sustainable production and assurance to employment and descent work as per sustainable development goals. ¹³ However, population health outweighs the effect of other factors, countries especially those in low and middle income regions should take urgent and bold measures instead for being blinded by cheap economic benefits of SSB and tobacco products (Table 1). Many tobacco and SSB industries are finding these countries as the new market hotspots for their products after having unstable market in high income countries. ⁴⁶ It will be more beneficial for countries to diversify their income sources to reduce dependence on these industries. ²⁷ In European countries, the implementation of SSB taxation policy have been found to be practical and useful toward reducing the demand for SSB as its intended goal despite the policy being opposed by food and beverage industries. ⁴⁰ , ⁴⁷ Alongside the introduction of tax and levy on unhealthy products, the primary motive should be health and not economic gain. ⁴⁸ , ⁴⁹ A good example is Uganda that dedicates a percentage of the tax on sugar to cover HIV/AIDs health services. ³¹ Philippines is also one among developing countries which has been successful in implementing health taxation products like tobacco and SSBs and use the revenues to fund healthcare services. ⁵⁰ , ⁵¹ , ⁵² This can serve as an alternative source of financing the health sector in limited resource settings.

Table 1.

Challenges and respective recommended solution to address economic priorities over public health dilemma in addressing NCDs in developing countries.

Challenges	Recommended solution
National and international economic policies which are not in favor of public health	Adapting and incorporation of health component in all national non‐health policies including economic policies like policies related to free‐marketing
Lack of funds to finance prevention and treatment services for NCDs	Dedication of a significant percentage of tax from SSB and tobacco products for financing preventive and treatment services for NCDs
Inadequate public awareness on the essence of taxation of sugar sweetened beverages and tobacco products	Provision of public health education on the purpose of taxation approach and means for self‐control
Fear of loss of sources of income to people (e.g., tobacco planters and processed food MSMEs) Fear for national gross domestic product reduction	Diversification of economic sources to people Diversification sources of national income
Massive advertisement of sugar sweetened beverages (SSB) and tobacco products	Impose advertisement restrictions to reduce the purchase of SSB and tobacco products
Easy accessibility and affordability of sugar sweetened beverages	Improve accessibility and affordability of other healthy drinks like milk and fresh fruit juice. Formulation of integrative policies including nutrition sensitive trade policies Insurance of equitable access to healthier options
Presence of cooperative union and boards that promote tobacco cultivation	Monitoring promotion of tobacco cultivation and its products

Abbreviation: NCD, noncommunicable diseases.

4. CONCLUSION AND RECOMMENDATION

Countries are facing dilemma on implementing economic interventions such as tax levy on SSB and tobacco product so as to reduce the use of unhealthy products and protect the health of the population. Majority of countries have used and relied on them to increase the national GDP instead of discouraging the use of SSB or tobacco products. Furthermore, due to perceived economic benefits, countries that have cooperative unions and tobacco boards face a contradictory effect in aborting tobacco cultivation and processing since these organs help to encourage and promote growth of tobacco industry. Countries should direct a significant percentage of revenues from tax obtained from SSB and tobacco products industries to NCDs preventive and control measures so as to compensate for the consequences.

The intertwined relationship of public health and economic development becomes more vivid when comes to prevention and control of modifiable risk factors for NCDs. Countries should raise their taxes to level that will pose constraints on purchasing unhealthy products and provide healthy education to enhance self‐control. Moreover, countries should enhance both intersectoral and multisectoral approaches, locally and internationally, in creating integrative policies with nutrition sensitive trade policies which harmonize both public health and economic growth during this era of globalization.

AUTHOR CONTRIBUTIONS

Baraka L. Max: Writing—original draft; data curation; conceptualization. Harold L. Mashauri: Conceptualization; writing—review and editing; data curation; project administration; supervision.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflict of interest.

TRANSPARENCY STATEMENT

The lead author Harold L. Mashauri affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

Max BL, Mashauri HL. Economic priorities over population health: A political dilemma in addressing noncommunicable diseases in developing countries. Health Sci Rep. 2024;7:e1974. 10.1002/hsr2.1974

DATA AVAILABILITY STATEMENT

Data sharing is not applicable to this article as no new data were created or analyzed in this study.