Commercial interests in health policy dialogues: a qualitative content analysis of NEDLAC’s engagement with South Africa’s Health Promotion Levy

Abstract

Background

Non-communicable diseases (NCDs) are rising rapidly in South Africa, prompting the introduction of the Health Promotion Levy (HPL) in 2018 to reduce the consumption of sugar-sweetened beverages. However, the levy remains below the rate recommended by the World Health Organization. One of the central institutions involved in the policy process leading up to and following the introduction of the HPL was the National Economic Development and Labour Council (NEDLAC), a statutory body designed to promote dialogue between government, business, labour, and community constituencies. This study examined NEDLAC’s mandate and its actual role in the HPL process, with particular attention to the inclusivity and transparency of its deliberations.

Results

Using an exploratory case study design, the research drew on qualitative content analysis of documents obtained through an access to information request made under South Africa’s Promotion of Access to Information Act 2 of 2000. The findings indicate that NEDLAC’s engagement with the HPL process fell short of its mandate to advance social equity and inclusive participation in economic decision-making. Community representatives, one of NEDLAC’s four official constituencies, were absent from all deliberations on the levy. In contrast, business representatives dominated the discussions, often advancing arguments aligned with the interests of the sugar industry and emphasising potential job losses despite limited supporting evidence. Moreover, the process lacked transparency, particularly regarding the authorship of NEDLAC’s HPL Report and the presentation of evidence used to support its conclusions.

Conclusions

NEDLAC’s handling of the HPL illustrates how participatory governance structures may, in practice, enable industry influence and weaken public health objectives. To enhance the integrity and effectiveness of policy dialogue on health-related fiscal measures, NEDLAC should adopt clearer procedural guidelines to ensure inclusive representation, strengthen transparency through public access to documentation, and institutionalise the role of civil society in its processes. Such reforms are essential to align participatory mechanisms with public health goals and to safeguard them from corporate capture.

Introduction

The continuing increase in non-communicable diseases (NCDs) (such as diabetes, cardiovascular diseases, cancer, overweight and obesity) globally and in South Africa has become one of the biggest contemporary public health challenges [1]. In South Africa, type 2 diabetes, stroke and heart disease (all of which have been linked to obesity) account for three of the top four causes of death and result in massive costs to the health system [2, 3]. Globally, there have been increased calls for effective interventions to curb this rising trend given concerns that failure to do this would lead to over 1.3 billion individuals being impacted by obesity worldwide by 2030 [4, 5]. The World Health Organization (WHO) introduced various “best buys” aimed at the prevention and control of NCDs [6]. One of these interventions is effective taxation on sugar-sweetened beverages (SSBs) to reduce sugar consumption [7]. It is recommended that countries introduce a tax on sugary drinks that increases prices by 20%, which can lead to a reduction in consumption of approximately 20% [8], thus preventing NCDs such as obesity and diabetes.

The adoption of fiscal measures such as SSB taxes reflects a broader global movement in health governance towards addressing the social and commercial determinants of health through market-based instruments [9]. These policy measures are shaped by the dynamics of globalisation, including international trade, investment, and corporate influence, which affect national governments’ capacity to regulate food environments [9]. In particular, trade and investment agreements may constrain regulatory autonomy through rules on non-discrimination, necessity, technical barriers to trade, and investor-state dispute settlement [10], which can create legal uncertainty or expose governments to litigation risks when introducing measures such as sugar taxes, front-of-pack labelling, or marketing restrictions. At the same time, international standard-setting bodies and normative frameworks, including Codex Alimentarius standards and WHO recommendations on fiscal and regulatory measures to address NCDs, can provide legal and evidentiary support for national interventions by reinforcing their scientific basis and public health rationale [11]. As such, debates around sugar taxation form part of a transnational policy dialogue on how global economic forces can be balanced with public health imperatives [12].

Across the African region, several countries have entered similar debates on implementing fiscal measures to curb excessive sugar consumption. For example, Botswana, Namibia, and Zambia have explored or announced plans to introduce SSB taxes following the WHO’s recommendations [13], while countries such as Kenya and Mauritius have already adopted SSB taxes or other excise taxes on sugar-sweetened beverages [14]. These regional developments reflect a growing recognition of the need for policy coherence across Southern and Eastern Africa in addressing NCDs linked to unhealthy diets.

Globally, sugar taxes have generated intense debate across political, economic, and industry arenas. Countries such as Mexico, the United Kingdom, and Chile have implemented SSB taxes with varying designs and levels of success, providing evidence of their potential to reduce consumption and incentivise product reformulation [15, 16]. However, these measures have also faced strong resistance from transnational beverage corporations, trade associations, and some ministries of finance and trade, who argue that such taxes threaten economic growth, employment, and trade competitiveness [17]. At the global policy level, discussions continue within forums such as the WHO, World Trade Organization (WTO), and other United Nations agencies on how to reconcile fiscal health measures with international trade and investment commitments [18]. For example, within WTO committees, member states have raised specific trade concerns about the design and potential trade restrictiveness of SSB taxes and related labelling measures, often questioning their consistency with non-discrimination and necessity principles [19]. In parallel, WHO processes, including discussions around Best Buys for NCD prevention and fiscal policy guidance, have been advanced by public health actors and supportive member states to promote the legitimacy and evidence base of such measures [20]. These debates underscore the broader tension between global health objectives and commercial interests, a defining feature of the political economy of NCD prevention. In this context, South Africa’s experience adds to the global discourse by illustrating how national policy actors navigate these competing pressures within a globalised economic system.

One of the responses to the WHO’s best buys was the introduction of the Health Promotion Levy (HPL) in South Africa, which is an excise tax on SSBs with an effective tax burden at implementation between approximately 10–11% [21]. This levy was included in the Rates and Monetary Amounts and Amendment of Revenue Laws Act 14 of 2017 and took effect on 1 April 2018. This stemmed from a 2016 policy proposal which announced an intention to levy a tax on SSBs with the aim of reducing sugar intake given its link to increased risk of NCDs [22–24]. The tax is based on sugar content given that SSBs are a heterogeneous group of products and have various levels of sugar [21]. This approach assists with targeting the source of SSB harms and encourages product reformulation [21].

South Africa’s experience with the HPL is particularly relevant in a global context because it illustrates how a middle-income country navigates competing global pressures, such as trade liberalisation, industry lobbying by transnational beverage companies, and international recommendations from bodies like the WHO, in advancing a public health fiscal measure. The HPL can therefore be viewed as a case that speaks to the interface between globalisation and health policy, offering lessons for other countries seeking to implement similar interventions under comparable economic and political conditions. In addition, examining the role of NEDLAC provides insights for countries with analogous multi-stakeholder or regulatory bodies that mediate between economic and public health objectives, such as Brazil’s National Health Surveillance Agency (ANVISA), which has faced significant political and industry contestation in regulating food, tobacco, and alcohol [25].

A key body in the process leading up to the implementation of the HPL was the National Economic Development and Labour Council (NEDLAC). As will be seen, NEDLAC is a statutory body aimed at bringing together government, labour, business, and community representatives to collaboratively promote sustainable growth, workplace equity, and stakeholder participation in economic decisions, in the review of labour legislation and socio-economic policies, and in reporting to the Employment and Labour Minister and Parliament. Part of NEDLAC’s mission involves promoting social equity, growth, and participation. A task team was formed by NEDLAC to “undertake a detailed analysis of the sugary sweetened beverages proposals with the view of reaching consensus” in 2017. In light of the involvement of NEDLAC with the HPL, this paper aimed to determine what the statutory mandate of NEDLAC entails (especially in relation to facilitating dialogue between labour, business and community representatives including those within the health fraternity) and what role it played and/or continues to play in the introduction and effective implementation of the HPL. This is important to understand given the crucial role that the HPL can play in combatting the rising rates of NCDs in South Africa and the function that NEDLAC serves in considering policies of this nature.

By situating this discussion within the broader global health governance discourse, this paper also contributes to understanding how national institutions engage with the commercial determinants of health and the global political economy of food and beverage industries. In doing so, it highlights the interconnectedness of national policy processes and global market structures, a core concern within the field of globalisation and health.

Methods

Design

This study utilised an exploratory case study methodology to analyse the role that NEDLAC played in the process leading up to the implementation of the HPL, and post-implementation relating to proposed increases of the tax. The exploratory study was coupled with an access to information request (also known as freedom of information) under the Promotion of Access to Information Act 2 of 2000. This Act aims to give effect to the constitutional right of access to any information held by the state or other parties, where such information is needed for the exercise of protection of any right (in this case public health). Both methods have been used in public health research to allow for in-depth studies and understandings of specific topics [26, 27]. Data obtained through the PAIA request was supplemented with a desktop review focusing on academic articles, government documents and popular media dealing with NEDLAC’s mandate and its role with the HPL.

Data collection

A PAIA request was made in line with the Act on 9 July 2024 to NEDLAC. The timeframe of interest was January 2016 to June 2024 given that 2016 was when the first policy proposal for an SSB tax was introduced. The following documents were requested:

1. Minutes of all meetings, including plenary sessions, working group meetings, task team meetings, and subcommittee meetings related to the Health Promotion Levy.

2. Agreements, memoranda of understanding (MOUs), and any other forms of formal agreements entered by NEDLAC regarding the Health Promotion Levy.

3. Reports, studies, research papers, and any other publications commissioned or produced by NEDLAC on topics related to the Health Promotion Levy.

4. Correspondence, including letters, emails, faxes, and memoranda exchanged between NEDLAC and relevant stakeholders, such as government departments, trade unions, industry associations, and civil society organisations, in relation to the Health Promotion Levy.

5. Any other relevant documents or materials pertaining to the Health Promotion Levy within the specified timeframe.

The first set of data was received on 23 July 2024 which comprised of 120 documents. On initial categorisation of the data, gaps were noted. Around 25 documents were noted as missing, with the majority being meeting minutes, and others including annexures and agendas. A follow up was sent on 17 October 2024 to request the outstanding documents, having noted that 12 from 2017, four from 2018, seven from 2019 to one each from 2020 to 2023, as well as none from 2022, were not received. After additional follow ups, a further 11 documents were received via email on 05 November 2024 and an additional 29 documents, which were only available in hardcopy form, was collected from the NEDLAC offices on 28 November 2025. Again, no documents from 2022 were received, and according to NEDLAC, these were all the documents they had.

Data analysis

The READ approach was used in this study to organise and analyse the data received. This structured method, commonly used in health policy research, involves four steps: Ready your materials, Extract data, Analyse data, and Distil your findings [28]. An Excel spreadsheet was also used for an initial screening to identify duplicates. In addition, any documents not relating to the HPL that were most likely mistakenly included, duplicates or insignificant draft copies were excluded. This led to 66 documents being excluded resulting in a final dataset of 94 documents. Given the focus of the paper around NEDLAC’s role with the HPL and proposed increases as well as the interest in the types of stakeholders involved in decision-making processes, the following categories were used to inductively code the data: HPL existence (relating to arguments for or against introducing the HPL); HPL percentage (pertaining to arguments around what percentage the HPL should be set at); HPL inflationary increase (relating to arguments for or against the need to increase the HPL for inflation); HPL extension (dealing with arguments for or against extending the HPL beyond just sugar-sweetened beverages to, for example, fruit juices); and how many stakeholders as well as the specific type of stakeholders that were represented from each group (looking at the key groups NEDLAC aims to include which are government, labour, business, and community). A round of blind-coding was done by two researchers, which was reviewed by a third researcher. Discrepancies were discussed and resolved by the three researchers. The results from the study are reported below.

Results

Understanding NEDLAC’s legislative mandate and composition

The desk review revealed that NEDLAC was established under the National Economic, Development and Labour Council Act 35 of 1994. The legislative mandate of the Council is outlined in Sect.  5(1) of the Act, which sets out its core objectives. These include the promotion of economic growth, broader participation in economic decision-making, and the advancement of social equity (Sect.  5(1)(a)). The Council is further tasked with seeking consensus and concluding agreements on matters related to social and economic policy (Sect.  5(1)(b)). Importantly, NEDLAC must consider all proposed labour legislation relating to labour market policy prior to its introduction in Parliament (Sect.  5(1)(c)), as well as evaluate any significant changes to social and economic policy before their implementation or submission to Parliament (Sect.  5(1)(d)). Additionally, the Council is mandated to encourage and promote the formulation of coordinated policy on social and economic matters (Sect.  5(1)(e)).

The African Union Development Agency (AUDA-NEPAD) describes NEDLAC as a statutory body that facilitates cooperation between government, labour, business, and community organisations, with the purpose of ensuring effective public participation in the development of socio-economic policy and legislation and fostering consensus and cooperation among the key social partners in addressing the country’s socio-economic challenges [29]. Reinforcing this, a 2023 statement issued by the Media Liaison Officer of the Department of Labour affirmed that “[NEDLAC] is the vehicle by which Government, labour, business and community organisations seek to cooperate, through problem-solving and negotiation, on economic, labour and development issues and related challenges facing the country” [30].

In terms of the composition of NEDLAC, as per Sect.  2(2) of the Act, the Council operates under the governance of an executive council and is structured into four distinct chambers: the Public Finance and Monetary Policy Chamber, the Trade and Industry Chamber, the Labour Market Chamber, and the Development Chamber. Section  3(1) further outlines the representational framework of the Council, specifying that it must include members drawn from four main constituencies: organised business, organised labour, organisations representing community and development interests, and the State.

In addition to the legislative framework, the NEDLAC Constitution reiterates and supplements several provisions of the Act. Notably, Sect.  12(4) of this Constitution provides for the functioning of meetings, stating that the quorum for executive council, committee (excluding the management committee), or chamber meetings shall be one-third of the members, with the added requirement that:

at least one third of the number of members representing each of the constituents are present.

The operational processes within these structures are guided by protocols such as the Protocol for Tabling Matters at NEDLAC. As stated in Sect.  7(3)(2) of the Protocol:

Once the matter has been tabled in the appropriate Chamber, Committee or Forum, that structure may in turn – establish a Task Team for the purpose of considering a particular set of proposals; and determine the number of representatives each Constituency may appoint to the Committee, which may not exceed six.

As will be seen from the review of documents received from NEDLAC, there were several instances where the constituencies were represented by more than six representatives.

An overview of the documents received from the PAIA request

As seen in Table 1, the total number of documents post-exclusion totalled 94. A limitation of this study is the potential existence of unknown additional documents that reflected NEDLAC’s engagement with the HPL, and that were not included in the analysis due to it not being received from the PAIA requests. However, for the purpose of this study, the available dataset was used as the basis for drawing conclusions.

Table 1.

Classification of NEDLAC HPL-related documents received from the PAIA request

Category type	No. of documents
Agendas	21
Communication	11
Decision matrices	4
Meeting records	16
Miscellaneous	3
Presentations	9
Progress reports	8
Reports	15
Terms of reference	7
Total	94

The 94 documents covered 2017 to 2023, spanning various categories that reflect different aspects of deliberation and decision-making. The largest category comprised ‘agendas’ (21 documents) and applied to different committees such as the Employment Tax Incentive Act Task Team, the Sugary Sweetened Beverages Task Team and for the Dialogue Session on the Socio-Economic Impact on the Increase of the HPL. The agendas and its items varied depending on the types of meetings, but broadly incorporated items such as adoption of terms of reference and presentations or discussions by NEDLAC or other stakeholders that pertain to a specific element of the HPL. While this figure of 21 may ordinarily indicate a great extent of planned discussions around the HPL, considering that this was over a period of seven years, 21 agendas equate to an average of three per year. However, having agendas does indicate the structured nature of engagements and suggests that the HPL was a recurring topic within NEDLAC’s agenda-setting processes.

‘Meeting records’ (16) and ‘reports’ (15) also constituted a significant proportion of the dataset, highlighting the emphasis on documenting discussions and summarising key outcomes. The former consists of minutes, attendance registers (markedly many of which were omitted in the first PAIA request, but that helped identify who were at the meetings) transcripts, and summaries of discussions, whereas the latter refers to all reports drafted by NEDLAC, for example including the NEDLAC Report on Sugary Beverages, as well as those reports, studies and technical assessments by other organisations. Examples of this include the ‘HPL Inception Report by Wesbound (Pty) Ltd’, the ‘Impact of the Sugar Tax on South Africa’s Non-Alcoholic Beverage Industry and the Macroeconomics Effects’, and the ‘Review and/or Assessment of the South Africa Public Health Policy and/or Product Tax Policy in Relation to Sugar-Sweetened Beverages (SSBs)’. The presence of 11 ‘communication’ documents, mainly comprising of emails and letters, over the seven years, suggests infrequent correspondence between stakeholders, government representatives, and industry actors.

Notably, there were fewer ‘decision matrices’ (4) compared to the volume of ‘agendas’ and ‘meeting records’, which may indicate a gap between discussions and formalised decision-making processes. Similarly, ‘progress reports’ (8) and ‘presentations’ (9) suggest ongoing monitoring and engagement, but their lower numbers could reflect a limited effort to systematically track the impact of discussions over time.

The ‘terms of reference’ (7) provide insights into the framework within which discussions occurred, while the ‘miscellaneous’ category (3) represents documents that did not neatly fit into the predefined classifications. The overall distribution of documents suggests a strong emphasis on procedural elements, discussion facilitation, and record-keeping, but potentially limited formal decision-making mechanisms within NEDLAC’s engagement with the HPL.

While various document categories were reviewed, this study focuses on ‘meeting records’, ‘reports’, and ‘presentations’ due to their substantive relevance to the research aims. These three categories provided the most insight into NEDLAC’s discussions, positions, and influence regarding the HPL. Other document types were either procedural or lacked sufficient depth for analysis within the scope of this results section.

Meetings of the Sugary Sweetened Beverages Task Team

The Sugary Sweetened Beverage Task Team was set up in the first half of 2017, and as per its Terms of Reference, the primary objective of this team was to engage on the policy proposal for sugary sweetened beverages by conducting a detailed analysis to reach consensus [31]. Initially, it’s purpose was to develop a report for submission to the Public Finance and Monetary Policy Chamber (PFMPC), outlining the positions of different parties, their reasoning, and areas of agreement or disagreement, while also providing recommendations for resolving any disputes [31]. Later on, it engaged on the progress of the implementation of the Government constituency’s jobs mitigation and creation plan [32]. Table 2 outlines the different meetings held by this Task Team between 2017 and 2019 (no record was found or received before or after this timeframe relating to meetings of the Task Team).

Table 2.

Attendance from NEDLAC’s four constituencies in the Sugary Sweetened Beverages Task Team meetings

Date	NEDLAC	Government	Labour	Business	Community	Total number of constituencies per meeting
08-Jun-17	2	7	2	9	0	20
06-Jul-18	2	3	2	6	0	13
07-Sept-18	2	5	1	4	0	12
26-Oct-18	2	5	1	6	0	14
10-Sept-19	2	8	2	6	0	18
01-Oct-19	2	1	1	5	0	9
22-Oct-19	2	4	1	3	0	10
Average number of constituencies that attended all meetings	2	5	1	6	0	14

Across the seven recorded meetings, the number of participating constituencies varied, with total attendance ranging from a low of nine constituencies (1 October 2019) to a high of 20 constituencies (8 June 2017).

Government representatives consistently had the highest participation, averaging five attendees per meeting and peaking at eight attendees on 10 September 2019. This suggests strong government involvement in discussions on the HPL, likely due to its policy and fiscal implications. It is interesting to note that in the initial setting up of the Task Team, the Government constituency indicated that one of their five suggested representatives were from the Department of Health. In contrast, business stakeholders had an average attendance of six per meeting, at times exceeding government participation, such as on 8 June 2017, where nine business representatives were present. This indicates substantial private sector engagement, reflecting the industry’s vested interest in the HPL and that they were allowed to consistently be involved and well represented in these discussions. This, is also, contrary to Sect.  7.3.2 of the Protocol for Tabling Matters at NEDLAC mentioned previously, as it exceeds the stipulated maximum of six representatives per constituency.

Labour and NEDLAC representatives attended meetings at relatively lower but consistent levels, with labour averaging one attendee per meeting and NEDLAC itself maintaining two representatives at every meeting. Despite job losses being a recurring theme in discussions (as will be seen below), the labour constituency’s low level of representation raises questions about how serious the issue of supposed job losses from the HPL truly was. If job losses were indeed a critical concern, greater and more consistent participation from labour might have been expected. This limited engagement suggests that the threat may not have been as urgent or contested within the labour constituency as often portrayed. The absence of community representatives across all recorded meetings is noteworthy, as it suggests a lack of civil society engagement in discussions on the HPL. This could imply that deliberations were primarily driven by institutional stakeholders rather than broader public health advocacy groups. The absence of community representatives in all recorded meetings also contradicts Sect.  3(1) of the NEDLAC Act, which requires representation from all four constituencies - government, business, labour, and community. In respect of chamber meetings, it also falls short of the quorum requirements set out in Sect.  12(4) of the NEDLAC Constitution, which stipulates that at least one third of the members representing each constituency must be present.

Overall, the average number of constituencies per meeting was 14, with notable fluctuations over time. The sharp decline in total attendance from 20 constituencies in June 2017 to nine in October 2019 suggests diminishing engagement over time, particularly from government and business sectors. This pattern may reflect shifting priorities, negotiation fatigue, or strategic disengagement by certain constituencies as discussions progressed. Furthermore, no records of SSB Task Team meetings were found after October 2019. This absence is notable given the continued debates surrounding the HPL post-implementation, suggesting that the Task Team may not have been fully utilised as a platform for ongoing dialogue and policy review.

The data highlights an imbalance in stakeholder representation, with business and government dominating discussions while labour remained marginal and community voices were absent. This has significant implications for the inclusivity and equity of the decision-making process regarding the HPL.

Reports created by or presented at NEDLAC

As outlined in Table 3, there were 11 reports either drafted by NEDLAC or other stakeholders in relation to the HPL between 2017 and 2023.

Table 3.

Reports drafted by NEDLAC or other stakeholders in relation to the HPL

No.	Date	Report title	Drafted by
1	15-May-2017	Taxation of Sugary Beverages in South Africa Socioeconomic Impact Assessment	Economic Tax Analysis Chief Directorate, National Treasury
2	17-Aug-2017	An Assessment of the Socio-Economic Impact of the Sugar Tax on the South African Sugar Industry by the Bureau for Food and Agricultural Policy (BFAP)	Bureau for Food and Agricultural Policy (BFAP)
3	23-May-2017	Technical Comments on Treasury’s SEIA	Business constituency
4	06-Oct-2017	Draft NEDLAC Report on Tax on Sugar Sweetened Beverages	NEDLAC
5	25-Jul-2019	Draft Independent Assessment Report of the Research and Findings Undertaken by the Members of the NEDLAC Sugar Task Team on Socio-Economic Impact Study of Health Promotion Levy (HPL)	Wesbound (Pty) Ltd
6	10-Sep-2019	HPL Inception Report by Wesbound (Pty) Ltd	Wesbound (Pty) Ltd
7	22-Oct-2019	Study on the Socio-Economic Impact of Health Promotion Levy Phase One Report Prepared by Wesbound (Pty) Ltd for NEDLAC Sugary Sweetened Beverages Task Team	Wesbound (Pty) Ltd
8	01-Sep-2020	Economic Impact of the Health Promotion Levy on the Sugar Market Industry Impact Assessment Report September 2020	Wesbound (Pty) Ltd
9	12-Dec-23	Dialogue Session on the Socio-Economic Impact on Increase of the Health Promotion Levy Held on 12 December 2023 from 10h00-12h00	NEDLAC
10	01-Nov-22	Impact of the Sugar Tax on South Africa’s Non-Alcoholic Beverage Industry & the Macroeconomic Effects	Pan-African Investment & Research Services (Pty) Ltd.
11	2023	Review and/or assessment of the South Africa public health policy and/or product tax policy in relation to Sugar-Sweetened Beverages (SSBs)	Anne Stone and Associates

Worth noting is that four of the 11 reports were drafted by Wesbound (Pty) Ltd. However, from the desk review, very little can be found about this company, as it even lacks a website from a general Google search. In fact, back in 2021, the Healthy Living Alliance (HEALA), an advocacy group, had noted similar issues:

Today, there is no publicly available information on how the NEDLAC report authors, Wesbound (PTY) Ltd, were appointed, the timeframe for the research or their terms of reference [33].

It is noted that only Report No. 1 in Table 3, from 2017 drafted by the Economic Tax Analysis Chief Directorate from National Treasury, contained wording that specifically advocated for the existence of the HPL. Four of the reports (No. 2, 4, 10 and 11) contained phrases that were explicitly against the existence of the HPL and five of the reports (No. 3, 4, 6, 7, and 8) considered the HPL existing, bearing in mind that Report No. 4 by NEDLAC fell into both these categories as it contained phrases that both opposed the HPL’s existence and also considered the HPL’s existence. For instance, it states:

Business does not agree that a SSB tax should be implemented [34].

Yet, acknowledging why the HPL came into existence by also stating:

The Minister of Finance announced in the February 2016 Budget a decision to introduce a tax on sugar-sweetened beverages (SSB) with effect from 1 April 2017 to help reduce excessive sugar intake [34].

In terms of the HPL percentage amount, only Report No.1 aligned with a 20% HPL, as the computable general equilibrium (CGE) model that was included in it was calibrated for a 20% tax. Report No.3 by the Business constituency was the only report that considered a tax below 20%, stating that in its calculations, it assumed that the HPL is equal to the general price increases before and after reformulation, in other words, 16% and 12,2% respectively. Notably, none of the reports advocated for a percentage above 20%, however, six of the 11 reports (No. 6–11) merely considered the notion of the HPL percentage amount without taking a stance on it, for instance, Report No. 9 stated:

The National Treasury is responsible for reviewing the tax amount annually. However, there has been no review of the HPL’s impact since its introduction [35].

When analysing the reports for reflections on increasing the HPL in line with inflation, it is noted that only Report No.1, once again by National Treasury, explicitly advocated for the HPL to increase with inflation, as it stated:

To ensure that the tax remains an effective intervention, the specific rate should be increased annually, at least by the expected rate of consumer price inflation [36].

Three of the reports (No. 8–10) merely considered the concept of inflation, such as Report No. 10 acknowledging that in order to avoid erosion in the HPL value due to inflation, the 2019 National Budget included that the HPL would be increased to 2,21 cent per gram in excess of 4 g. Only Report No. 11 by Anne Stone and Associates (although it is uncertain which constituency they represent) was explicitly against aligning the HPL with inflationary increases.

Lastly, in terms of extending the HPL to products such as fruit juices, none of the reports explicitly advocated for this. However, eight of the 11 reports (No. 1, 3, 4, 6–10) merely considered the idea of HPL extension, such as Report No. 8 by Wesbound (Pty) Ltd noting that 100% fruit juices are exempted from the HPL. There was just one report, No. 11 by Anne Stone and Associates, which did not support extending the HPL to 100% fruit juices, as it stated:

Taxing fruit juice could make this impossibly expensive. Taxing fruit juice also risks sending out the wrong message around fruit, which is something people are encouraged to include in a healthy diet [37].

Presentations

Table 4 contains the nine presentations that were either created and/or presented by or on behalf of NEDLAC or created and/or presented by other stakeholders to NEDLAC in relation to the HPL between 2017 and 2023.

Table 4.

Presentations by NEDLAC or other stakeholders in relation to the HPL

No.	Date	Presentation title	Drafted by
1	17-Feb-2017	Proposed Tax on Sugary Beverages: Policy Rationale	NEDLAC
2	17-Feb-2017	Tax on Sugary Beverages: Socio-Economic Impact Analysis	NEDLAC
3	12-Aug-2017	Business Response to the Jobs Mitigation and Creation Plan (JMCP) in Response to Health Promotion Levy (HPL)	Business Constituency
4	04-Aug-2017	Jobs Mitigation and Creation Plan for Sugar Value Chain Presentation to NEDLAC SSB Task Team	NEDLAC
5	06-Feb-2019	Presentation to NEDLAC Sugar Tax Meeting Progress on Review of the Sugar Industry Regulations	Department of Trade, Industry (and Competition)
6	21-Aug-2019	South African Emerging Farmer Research, I.R.O Index Insurance / Weather Based Insurance	South African Insurance Association
7	10-Sep-2019	NEDLAC Inception Presentation - Wesbound	Wesbound (Pty) Ltd
8	23-Nov-2020	Research Report Submitted to NEDLAC on the Economic Impact of the HPL on the Sugar Market Industry	Wesbound (Pty) Ltd
9	12-Dec-2023	Sugar Tax Imbizo Food Stuff Taxation & Public Health	The Beverage Association of South Africa (BevSA)

Of the nine presentations, there were none that specifically advocated for the existence of the HPL, and notably there were no presentations by health-related entities nor civil society groups. However, four of the presentations (No. 1, 2, 7 and 8 in Table 4) merely considered the HPL’s presence, for instance, Presentation No. 1 outlined the scope, tax base and rate of the HPL. Only Presentation No. 3 was explicitly against the existence of the HPL, as it stated:

Business is not in support of the proposed SSB tax. Participation at NEDLAC must not be construed as supporting the tax or that the present mitigation approach by Government will result in effective job preservation [38].

In terms of the HPL percentage, none of the presentations advocated for the HPL to be 20% or above. Rather, only four presentations (No. 1, 2, 7 and 8 in Table 4) considered the HPL percentage, such as Presentation No. 7 quoting results from studies on the HPL and its effect on decreasing obesity prevalence while using a tax rate of 20%, and then recommending:

An extended review of the relationship between sugar and obesity (obesity related diseases) [39].

When analysing the presentations and its points with regard to increasing the HPL to align with inflation, only two presentations (No. 1 and 8 in Table 4) considered or merely mentioned inflationary increases of the HPL. For example, Presentation No. 8 merely stated that the specific tax rate is revised annually for inflation, with the last change being made on 01 April 2019 [40].

Lastly, of the nine presentations, only three presentations (No. 1, 2 and 7) considered the concept of extending the HPL to be applied to fruit juices, such as Presentation No. 2 which incorporated 100% fruit juices into the socioeconomic impact analysis study of the HPL.

Discussion

The lack of participation by the community constituency is concerning

One of the most glaring shortcomings of NEDLAC’s engagement with the HPL is the complete absence of public health experts, non-governmental organisations (NGOs) that advocate for public health, and community-based organisations focused on health promotion or NCDs. The non-participation of these stakeholders fundamentally undermines the ability of NEDLAC to holistically consider the HPL’s impact, as discussions are largely dominated by economic interests, particularly those of the sugar industry. At best, neither the NEDLAC Act nor the NEDLAC Constitution explicitly permits the absence of any of the four constituencies. Section  3(1) of the Act outlines the composition of the Council as including all four parties - government, business, labour, and community - implying their consistent presence. Given NEDLAC’s core purpose of bringing together diverse voices to build consensus on socio-economic policy, the absence of any constituency undermines the spirit and intended function of the institution.

Based on the NEDLAC Act, it is argued that NEDLAC was originally conceived as a platform for inclusive dialogue, aimed at bringing together government, business, labour, and community-based constituencies to formulate coordinated policy responses. In its official overview of its history, NEDLAC states that it was designed to “give voice to marginalised groups such as the unemployed, disabled, youth, and women and avoid narrow corporatism” [41]. However, in practice, the representation of community-based interest groups, particularly those advocating for public health, has been absent from discussions on the HPL.

This omission is particularly concerning given NEDLAC’s legislative mandate, and this structural deficiency raises critical questions about whether NEDLAC is fulfilling its intended role as a platform for inclusive policy dialogue. Section  5(1)(e) of the NEDLAC Act, which is reinforced by Sect.  4.1(e) of the NEDLAC Constitution, mandates the institution to “encourage and promote the formulation of coordinated policy on social and economic matters” [42]. While economic concerns, such as the impact of the HPL on the sugar industry and employment, have been prominently discussed, the broader social imperative of reducing sugar consumption and mitigating public health harms, such as obesity and diabetes, has been sidelined.

In fact, not including public health experts in the HPL-related meetings does not align with the suggestion by the Chairperson of the Standing Committee on Finance of the National Assembly, who in a letter in 2017, wrote the following to NEDLAC’s executive director:

If it is appropriate at all to raise this, our Committee would like NEDLAC to consider the following: …engaging with HPL stakeholders not represented in NEDLAC [43].

Failing to include the community constituency in discussions around the HPL, is not an outlier event. In a recent study that aimed to explore the industry activities related to the Draft Liquor Amendment Bill 2016 within NEDLAC, it found:

Although ‘community’ are named as a key actor within NEDLAC, they appeared to have much less representation than other groups in the committees we identified and we found no evidence to suggest they were involved in the 2017 NEDLAC report on the Bill” [44]

By failing to include public health voices, NEDLAC’s discussions on the HPL or even the Draft Alcohol Amendment Bill 2016 have been skewed in favour of economic actors with vested interests. The absence of organisations that represent communities most affected by non-communicable diseases (NCDs) means that the full spectrum of costs and benefits associated with the levy is not adequately considered. As a result, the policymaking process within NEDLAC is imbalanced, favouring short-term economic arguments over long-term public health objectives. This is particularly concerning considering that an evaluation of the HPL highlighted that one of the groups that benefited the most from the HPL was lower socio-economic groups [21].

This pattern of non-participation of public health stakeholders resonates with wider literature on corporate political practices, where industries strategically dominate participatory spaces to advance economic arguments while marginalising public health voices. For example, Lacy-Nichols et al. [45] describe how corporations deploy a “playbook” of tactics to frame regulation as economically harmful, while Lauber et al. [46] show how food industry actors shaped WHO consultations by emphasising risks to trade and jobs rather than health. Similarly, Mialon et al. [47] document extensive lobbying in Colombia’s front-of-pack labelling debates, illustrating how corporate actors overwhelm participatory processes to dilute health measures.

Beyond the HPL, it is important to recognise that sugar taxes form only one component of a broader set of policy tools to address the commercial determinants of health in food systems. Other complementary measures include restricting the marketing of unhealthy foods and beverages (particularly to children) [48], mandating clear front-of-pack nutrition labelling [49], reformulating products to reduce sugar, salt and fat content [50], and implementing fiscal or procurement policies that promote access to healthy foods [51]. These interventions work synergistically with fiscal measures like the HPL to shift both corporate practices and consumer environments, creating a more comprehensive public health response to diet-related diseases. However, such measures also require inclusive dialogue platforms like NEDLAC to ensure they are not captured or diluted by industry interests, hence the need for NEDLAC to correct its approach for policies that affect health.

Industry arguments are flawed

A central argument advanced by the sugar industry throughout NEDLAC’s engagement with the HPL has been its purported impact on employment. Industry representatives have consistently framed the levy as a direct cause of job losses in the sugar sector, warning of dire economic consequences should it remain in place or be increased. This argument has been a key driver in shaping NEDLAC’s discussions, often influencing policymakers to adopt a more cautious approach towards strengthening the levy.

However, recent empirical evidence challenges this narrative. A study employing a single-group interrupted time series analysis, using data from Statistics South Africa’s Quarterly Labour Force Survey, found no significant association between the introduction of the HPL and job losses, or job creation, in sugar-related industries [52]. This finding directly contradicts industry claims and suggests that factors other than the HPL are responsible for employment trends in the sector.

Above and beyond the basis of the job-losses argument being flawed, one of the main aims of the NEDLAC and HPL engagements was to mitigate the potential for job losses, as even in a presentation in 2017 by the NEDLAC SSB Task Team, stipulated that:

[Jobs Mitigation and Creation Plan (JMCP)] to be developed and activated to address potential job loss as a result of SSB implementation. JMCP aims to prevent/ lessen job loss in the value chain [53].

In a June 2017 letter from the Chairperson of the Standing Committee on Finance in the National Assembly to NEDLAC’s Executive Director, it was noted:

The Finance Committee is working closely with the Health Committee in processing the HPL. The Committees have not come to any consensual position on the HPL yet, but the majority seems sympathetic to the HPL provided that there are not significant job losses and the negative consequences for emerging cane growers and other entrepreneurs in the sugar industry is kept to a minimum [43].

Given that subsequent studies have shown the HPL did not result in significant job losses, and that dedicated task teams were established to mitigate potential employment impacts, NEDLAC’s stance - or its willingness to entertain the view - that the HPL has caused job losses appears misaligned with both the available evidence and the broader policy context.

NEDLAC’s stance on HPL has failed public health

NEDLAC’s engagement with the HPL reveals a troubling inclination to prioritise industry concerns over the intended public health objectives of the policy. Despite clear evidence that the HPL was introduced to curb excessive sugar consumption and reduce the incidence of NCDs, NEDLAC’s deliberations have frequently echoed industry arguments that frame the levy as a threat to jobs and economic stability. Evidence has also shown that lower socioeconomic groups experienced larger reductions in the purchase of sugar-sweetened beverages post the implementation of the HPL [21], and bearing in mind that NEDLAC has an objective of advancing social equity, these types of evidentiary points should have centred more prominently in its engagement relating to the HPL. However, NEDLAC’s alignment with the business and labour constituency’s stance has created a platform where public health considerations are often marginalised. Industry stakeholders have consistently argued that the HPL has resulted in widespread job losses and economic harm, yet these claims are frequently overstated and lack robust, independent verification. In fact, in a study that mapped out food industry strategies to influence public health policy, research and practice in South Africa, Mialon et al. identified that industries employ discursive strategies in relation to the economy by stressing the number of jobs that are supported by a particular food item/production and that a policy will lead to reduced jobs [54], which is precisely seen from the business constituency’s participation in NEDLAC with respect to the HPL. Rather than critically engaging with this narrative, NEDLAC has often accepted these assertions at face value, which has stymied meaningful policy debate and delayed or diluted further public health interventions. Despite National Treasury’s stance also being that the HPL has to be increased annually for inflation in order to remain an effective intervention, NEDLAC has not stressed this point enough in its reports.

This positioning has significantly weakened the transformative potential of the HPL as a tool for health promotion. By allowing economic concerns, especially those driven by private sector interests, to dominate the discussion, NEDLAC has inadvertently constrained the broader public health agenda. The lack of strong advocacy for health outcomes during NEDLAC meetings, such as reduced sugar consumption, improved population health, and long-term cost savings in the healthcare system, demonstrates a failure to balance economic considerations with the urgent need for preventive health measures. Furthermore, this deference to industry’s narrative risks setting a precedent where any health-related fiscal intervention can be derailed by unsubstantiated claims of economic damage, ultimately undermining the state’s capacity to implement effective public health policies through evidence-based regulation. The fact that similar trends were seen in relation to the Alcohol Bill highlights that NEDLAC is not being utilised to its full capacity and if anything, is being misused by business constituencies to further their interests at the cost of public health. This goes against NEDLAC’s mandate, as discussed and undermines its mandate to consider community groups and interests.

More broadly, this pattern highlights a systemic challenge in addressing the commercial determinants of health within South Africa’s food system governance. As seen globally, multi-sectoral dialogue platforms often face strong resistance from industry actors seeking to delay, dilute or divert public health measures [55]. Strengthening transparency, conflict-of-interest management, and evidence-based decision-making within such forums is therefore critical not only for the success of the HPL but also for advancing other interventions aimed at transforming unhealthy food environments.

Recommendations

To ensure that NEDLAC functions as an effective platform for inclusive and evidence-based policymaking, several key reforms are necessary. These recommendations aim to improve transparency, procedural clarity, and stakeholder representation, particularly in relation to the HPL and broader public health policy discussions.

One of the fundamental weaknesses of NEDLAC’s structure is the lack of clarity on how and when its four constituencies (government, business, labour, and community) interact with one another. Neither the NEDLAC Act nor the NEDLAC Constitution provide detailed guidance on the processes governing these engagements. As a result, discussions can be dominated by particular constituencies, leading to imbalanced decision-making, as highlighted in the discussion above. To address this, NEDLAC should establish formalised guidelines that specify how these constituencies are coordinated, ensuring that all perspectives are adequately considered in policy deliberations. A structured framework for cross-chamber/constituency engagement will help prevent undue influence from dominant industry players while fostering more comprehensive policy discussions.

The processes through which NEDLAC conducts investigations and reaches conclusions remain opaque. Neither its Act nor its Constitution outlines the specific procedures governing its inquiries. This lack of transparency raises concerns about the robustness of evidence used to inform policy recommendations. To enhance accountability, NEDLAC should introduce publicly accessible documentation detailing the steps involved in its investigations, including criteria for evidence evaluation, stakeholder consultation processes, and decision-making mechanisms. Establishing clear procedural guidelines will help build public trust and ensure that policy discussions are guided by objective, evidence-based assessments rather than industry-driven narratives. Furthermore, currently, the only publicly available document detailing NEDLAC’s engagement with the HPL is the HPL Impact Assessment Report from 2020. There is no access to summary reports of task team and committee meetings, nor are there regular updates on the institution’s ongoing deliberations regarding the levy. This lack of transparency severely limits public oversight and informed participation. NEDLAC should commit to making all relevant documents, including meeting summaries, key deliberation outcomes, and periodic progress reports, easily accessible on its website. Additionally, regular media briefings should be held to ensure that the broader public, particularly affected communities, remains informed of NEDLAC’s work on health-related policy issues. Improved transparency will not only enhance accountability but also help counter the perception that NEDLAC serves as a closed forum for elite economic interests.

A well-rounded policy discussion on the HPL, or any public health-related policy, requires input from all four constituencies within NEDLAC. However, the non-participation of community organisations and public health advocates from all HPL-related engagements has significantly weakened the credibility of these discussions. It is imperative that NEDLAC actively integrates community representatives (given that this is part of its mandate) as well as representatives from public health, consumer rights groups, and development-focused organisations to ensure that community and health concerns are not overshadowed by economic interests. This could be achieved through dedicated forums for public health discussions within NEDLAC or by mandating the inclusion of public health experts in task teams dealing with health-related policies. Without these voices, discussions remain one-dimensional, reinforcing economic arguments at the expense of public well-being. It should also be stressed that failure to include community representation violates NEDLAC’s mandate. When NEDLAC convenes meetings and engages on key socio-economic issues, it should ensure that these processes are clearly communicated in advance to allow all interested parties the opportunity to participate. This would enhance transparency and inclusivity. Additionally, comprehensive summaries reflecting the inputs of all constituencies should be made publicly accessible, rather than final reports like the Wesbound (Pty) Ltd Impact Assessment Report, which is the only HPL-related material currently available on NEDLAC’s website.

By implementing these recommendations, NEDLAC can strengthen its role as a platform for inclusive and evidence-based policy dialogue. Ensuring clarity in its structural processes, improving transparency, and incorporating diverse perspectives, especially those representing public health, will help restore the institution’s credibility and enhance its effectiveness in shaping policies that serve the broader public interest.

From a global perspective, the South African case provides valuable lessons for other countries navigating the intersection of health and economic policy. First, it underscores that institutional design matters, multi-sectoral platforms intended to balance economic and social objectives must have clear safeguards to prevent dominance by commercial actors. Second, it illustrates that fiscal health measures such as sugar taxes are most effective when supported by transparent, participatory, and evidence-based governance structures. Finally, it highlights the importance of embedding public health expertise and community participation within social dialogue mechanisms, a lesson that can inform the design or reform of similar institutions across LMICs. Strengthening such participatory mechanisms globally could enhance accountability in addressing the commercial determinants of health and accelerate the translation of health-promoting fiscal measures into equitable outcomes.

Conclusion

This paper has highlighted the shortcomings of NEDLAC, through its involvement in the HPL, in its ability to meet its mandate relating to the promotion of “broader participation in economic decision-making, and the advancement of social equity”. In particular, it illustrates a clear lack of involvement of community representatives even though they are one of the four constituencies that need to be involved in its deliberations. Of greater concern is the fact that this does not seem to be an isolated issue given that similar deficiencies were raised in the context of the Alcohol Bill. Given the potential that NEDLAC holds to ensure participation in policy-making processes, the deficiencies highlighted need to be urgently remedied as they have implications not only for public health but for broader inclusion in all policies.

At a global level, the South African experience demonstrates that even well-intentioned participatory mechanisms can be co-opted when commercial interests outweigh health priorities. The lessons learnt from this case emphasise the necessity for other countries to establish institutional checks that protect public health policy from industry influence, while ensuring inclusive, transparent, and evidence-based engagement. These insights are relevant for international policy processes seeking to address the commercial determinants of health and can contribute to global dialogues on creating healthier and fairer food systems.

Abbreviations

HPL

Health Promotion Levy

NEDLAC

National Economic Development and Labour Council

SSB

sugar sweetened beverages

Author contributions

DN led the conception and design of the study, collected and coded the data, interpreted the findings, and drafted the manuscript. NN contributed by double coding the data. SG contributed to the study’s conceptualisation, design and provided critical revisions to the manuscript. SM was involved in the study’s conception and design, reconciled the double coding with the primary coding, contributed to drafting the manuscript, and critically reviewed it.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Competing interests

The authors declare no competing interests.