Political prioritization of alcohol and sugar-sweetened beverage taxation in Uganda: Agenda dynamics amidst a shifting funding landscape

Abstract

Introduction

Uganda faces a rising burden of noncommunicable diseases (NCDs) at a time when pressure to mobilize domestic health financing is increasing. These challenges have become more acute since January 2025, when geopolitical shifts and donor fiscal tightening led to substantial reductions in external health funding. Consequently, policymakers have renewed interest in health taxes as a mechanism both to reduce consumption of harmful products and generate domestic revenue for health. While tobacco taxation has received sustained policy attention, largely due to the influence of the WHO Framework Convention on Tobacco Control, considerably less is known about the political dynamics shaping alcohol and sugar-sweetened beverage (SSB) taxation. This study therefore examines the factors contributing to the relatively low prioritization of alcohol and SSB taxes within Uganda’s policy agenda.

Methods

Guided by the framework on political priority, we conducted 25 semi-structured interviews with stakeholders from government, parliament, civil society, academia, industry, and the media. We also reviewed 22 documents from 2015 to 2025, including policy papers, fiscal records, parliamentary debates, and industry materials. We analyzed the data thematically following an inductive thematic analysis approach. Coding was informed by the framework and strengthened through triangulation across interviews and documentary sources to enhance credibility.

Results

We identified three levels of barriers. First, transnational norms promoted health taxes, but regional tax harmonization commitments within the East African community constrained national policy space. Second, domestic advocacy was weakened by fragmented ministerial mandates, limited local evidence, retreating policy entrepreneurs, and industry lobbying. Third, within the national political environment, the multiparty legislative dynamics, the high cost of sponsoring private members’ bills, and revenue-centric fiscal framing limited traction. The 2025 donor financing contraction acted as a focusing event that revived debate on health taxes primarily as domestic health financing stabilization instruments rather than NCD prevention tools.

Conclusion

While policymakers support health taxes to curb NCDs and increase domestic revenues, taxes on alcohol and SSBs remain underprioritized in Uganda due to institutional fragmentation, political-economic incentives, and legislative resource constraints. As external financing declines, it will be essential to strengthen locally grounded evidence, cross-sector coalitions, and integration of health objectives into fiscal reforms. In this way, health taxes represent a durable policy option for quickly mobilizing financial resources for health and preventing NCDs.

Introduction

By 2019, Noncommunicable diseases (NCDs) caused one in three deaths in Uganda, with hypertension, diabetes, chronic respiratory diseases, cancer, and cardiovascular diseases as leading causes [1, 2]. Tobacco, alcohol, and unhealthy diets are Uganda’s leading risk factors for morbidity and mortality [3]. According to the World Health Organization (WHO) STEPS survey, one in three adults in Uganda reported alcohol consumption in 2023 [4]. A localized survey of adolescents and young adults in Uganda found that one in three consumed sugar-sweetened beverages (SSBs) 2–3 times per week [5]. Relatedly, 8.3% reported current smoking in 2023 (down from 9.6% in 2014).

The Ministry of Health (MoH) expressed intent to prioritize NCD risk mitigation during the 2015–2020 Uganda Health Sector Development Plan through early diagnosis and treatment. Within this plan, they allocated about 17% of the total health budget to NCDs, with 60% of that budget aimed at prevention programs [6]. While the health budget has doubled between 2024 [7] In 2026, funding for NCDs remains uncertain [8] in part due to limited transparency in what NCD allocations are while spending continues to prioritize communicable diseases (HIV, TB, malaria) and maternal and child health [3]. Given the political interest in curbing NCDs and the lack of funding actively invested in prevention activities, health taxes offer a potential way to address NCDs without significant health sector reform [9].

WHO guidance on alcohol taxation has evolved steadily since 2010 through strategic frameworks, tools, and technical manuals [10–12]. In contrast, Uganda’s progress has been limited, reflected in the 2014 Excise Duty Act, a 2019 alcohol policy, modest revisions in 2024, and a narrow 2025/26 adjustment indicating slow reform and unresolved policy constraints [13]. In 2018, WHO promoted taxes on sugar-sweetened beverages (SSBs) to reduce consumption and lower obesity and diabetes risks, but Uganda has not adopted this approach widely [14]. Although excise duties exist on soft drinks, they do not target sugar content or meet the recommended 20% threshold and are driven mainly by revenue goals rather than health objectives, as these taxes sit within broader luxury goods duties. Details of these excise duty structures are presented in Table 1 below;

Table 1.

Current Structure of excise duty on alcohol and SSBs

	Product category	Excise duty rate/amount	Year of last amendment	Structure
1	Non-alcoholic beverages (SSBs / soft drinks)	12% ad valorem or UGX 250 per litre (whichever is higher)	2023	Applies broadly to soft drinks and SSBs with no differentiation by sugar content
2	Powder for reconstitution (excluding juice pulp)	15% ad valorem	2023	Covers drink powders used to prepare SSBs
3	Fruit & vegetable juice (< 30% local pulp)	12% or UGX 250 per litre	2023	Exemption applies if ≥ 30% local pulp
4	Fruit & vegetable juice (≥ 30% local pulp)	Exempt	2023	Industrial policy incentive for local agriculture
5	Beer – malt	60% or UGX 2,050 per litre	2024	Higher rate on commercially produced malt beer
6	Beer – locally produced/opaque	20% or UGX 230 per litre	2024	Preferential rate to support local production
7	Spirits – imported	100% or UGX 2,500 per litre	2024	Highest excise burden; public health & revenue rationale
8	Spirits – locally produced	80% or UGX 1,700 per litre	2024	Lower than imported spirits
9	Wine – imported	80% or UGX 8,000 per litre	2024	Strong protectionist and revenue focus
10	Wine – locally produced	20% or UGX 2,000 per litre	2024	Preferential local rate

Uganda’s health financing landscape shifted markedly after January 2025 following significant reductions in external development assistance, including the withdrawal or restructuring of major bilateral programmes that had historically supported health-system operations [15]. The reset exposed longstanding structural dependence on donor financing and intensified pressure on the government to expand domestic revenue sources to sustain essential services, including health [16, 17]. Policy discussions within government and development partner forums are increasingly centered on innovative financing mechanisms capable of generating domestic revenues. In this context, taxes on health-harming commodities resurfaced not only as population-health interventions but also as potential instruments for revenue mobilization [18]. For these reasons, there could not be a more reasonable time to reimagine critical tools for sustainable revenue like taxes on alcohol and SSBs. Understanding why such measures had historically failed to gain political traction became newly urgent within this altered fiscal environment.

Commitments such as the 2023 Lusaka Agenda for increased domestic financing for health and current priorities around innovative health financing [19] recognize how health taxes may serve as critical tools for sustainable revenue and NCD prevention for the Ugandan government. In this moment of donor disruption, it is critical to consider what innovative solutions exist and why historically health taxes on alcohol and SSBs have been sidelined.

This analysis focuses on alcohol and SSB taxation rather than tobacco for three major reasons. First, Uganda has comparatively advanced tobacco control legislation, including domestication of the WHO Framework Convention on Tobacco Control and an established taxation architecture, resulting in a more institutionalized policy domain than that governing alcohol and SSBs. Second, tobacco fiscal policy has received considerably greater scholarly and policy attention within the region [20, 21], while political prioritization dynamics surrounding alcohol and SSBs taxation remain underexplored. Third, examining commodities with weaker regulatory consolidation allows clearer analysis of agenda-setting processes where institutional norms and advocacy coalitions are less mature. This focus therefore enabled investigation of political prioritization under conditions of emerging rather than established governance. Against this backdrop of fiscal transition and evolving governance incentives, this study examined how political prioritization processes shaped attention to alcohol and SSB taxation within Uganda’s policy environment.

Methodology

We used the Shiffman and Smith framework (2007) to examine the political prioritization of alcohol and SSB taxation in Uganda, focusing specifically on the agenda-setting and policy formulation stages of the policy process [22, 23]. An exploratory qualitative design was employed to investigate how actor power, ideas, political contexts, and issue characteristics shaped the emergence and prioritization of these fiscal measures (see Table 2). The framework has been widely applied to understand why some health issues gain political attention while others do not, including in maternal health, mental health, tobacco control, sexual and reproductive health, and sexually transmitted infections [22, 24–27].

Table 2.

Shiffman and Smith Framework (2007) Components for Analyzing Health taxes Political Prioritization

Framework Domain	Core Components	What the Domain Examines	Relevance to Health Taxes in Uganda
Transnational Influence	Global norms and ideas	How international norms, guidance, and external actors shape national agendas and policy attention	Captures the role of WHO, UN resolutions, World Bank guidance, and regional obligations (e.g. EAC tax harmonization) influencing Uganda’s health tax debate
	International actors and institutions
	Technical and financial resources
Domestic Advocacy	Policy community cohesion	How national actors mobilize, frame, and advocate for an issue, and whether they sustain momentum	Explains fragmented inter-ministerial mandates, weak advocacy coalitions, limited local evidence, and industry counter-framing undermining health tax adoption
	Political entrepreneurship
	Credible indicators and evidence
	Framing of the issue
	Focusing events
National Political Environment	Political institutions and governance.	How broader political and institutional contexts enable or constrain policy action	Illuminate transactional parliamentary processes, costly private member bills, multiparty dynamics, and competition with other health and economic priorities
	Party politics and legislative processes
	Competing policy priorities
	Political transitions

We selected this framework because it provides a vital lens for analyzing how policy actors frame issues, mobilize support, and navigate political opportunities and constraints. While not originally designed to analyze commercial determinants of health or legislative bargaining in depth, these dimensions emerged strongly in our findings and were interpreted alongside insights from the political economy and commercial determinants literature. Given the limited evidence on alcohol and SSB taxation in Uganda, an open-ended interpretive approach was appropriate for understanding how competing interests, institutional dynamics, and policy narratives shape political prioritization.

Data collection

We used two primary data collection methods: qualitative interviews with key informants and documentary analysis of publicly available documents. We employed document analysis to analyze existing written materials by systematically searching five databases, including PubMed, Google Scholar, Scopus, African Journals Online, and the WHO IRIS repository, using search terms such as “health tax*,” “alcohol tax*,” “sugar tax*,” OR “beverage tax*” AND “Uganda” OR “East Africa*.” In addition, we hand-searched websites of Uganda’s Ministry of Health, Ministry of Finance, Parliament of Uganda Hansard, Uganda Revenue Authority, The Uganda Legal Information Institute, and East African Community Secretariat [28, 29]. We also identified grey literature through citations in key documents and recommendations from key informants.

We reviewed 22 key documents from government policies, program reports and guidelines, annual health sector performance reports, financial documents, gray literature and project reports, international frameworks, online resources, and published literature. The inclusion criterion was a ten-year duration between 2015 and 2025. Documents addressed: (1) fiscal policies for NCDs; (2) alcohol or SSB taxation; (3) legislative debates on health taxes; or (4) industry positions on beverage taxation. We excluded general NCD prevention documents that did not discuss fiscal measures. This approach was consistent with established procedures for documentary analysis [30].

We also purposively identified participants by role to ensure representation from key stakeholder groups, including policymakers (11), civil society and academia (8), industry-affiliated actors (5), and media (1), and contacted them with explanations of the study aims. Industry-affiliated participants included representative business associations such as the umbrella organization for manufacturers, the umbrella organization for private-sector actors, as well as the City Traders’ umbrella association. These organizations were included because they actively participated in policy discussions affecting commercial sectors and were treated analytically as industry-aligned stakeholders. Given their advocacy role, interview data were interpreted alongside documentary evidence and perspectives from other stakeholder groups to account for potential strategic framing and selective disclosure. Those consenting scheduled interviews at agreed-upon times and venues. Additional respondents were recruited via participant recommendations linked to the legislative process. A tailored, pre-tested interview guide was used. Informed consent preceded all interviews. Three authors (ES, HZ, and RS) conducted face-to-face and virtual sessions. Overall, out of the thirty potential respondents approached to participate in this study, twenty-five respondents were finally interviewed. The interviews followed a semi-structured format, lasted 30–60 min, and were audio-recorded for accuracy, as presented in Table 3 below.

Table 3.

Respondent categories

	Category	Number
1	Ministry of Health (MoH)	4
2	Ministry of Finance, Planning and Economic Development	2
3	Ministry of Trade, Industry and Cooperatives	2
4	Parliament of Uganda	3
5	Civil Society Organization	5
6	Academia/Researchers	3
7	Industry front groups	5
8	Media	1
	Total	25

Data analysis

A thematic approach as described by Braun and Clarke (2006) was followed [31]. It involved familiarization, initial coding, theme searching, theme review, theme definition/naming, and writing findings. Codes were anchored in Shiffman and Smith’s framework, whereby each domain of the framework formed a parent code and the subdomains within each domain formed child codes (see Table 3), with relevant text highlighted and assigned in Atlas. ti. Thematic synthesis integrated coded segments into coherent insights. Initial coding and preliminary synthesis were conducted by two of the authors (ES & HZ), with variations over interpretation resolved during team meetings and member checking. Additional feedback and interpretation of results were obtained from stakeholders during the dissemination workshop. Representative transcript excerpts from both interviews and key documents reviewed were incorporated as quotations to preserve participants’ voices and substantiate interpretations, enhancing credibility, transparency, and traceability from raw data to reported themes across the qualitative results.

We triangulated findings from documents and interviews iteratively. We identified key themes and events in first-stage document analysis that informed interview guide refinement. We probed stakeholders about documentary findings to understand context and motivations. We also triangulated themes that appeared in: 1) multiple stakeholder categories; 2) both documents and interviews; and 3) independent data sources. Particularly salient in this area was how ‘industry opposition’ was documented in parliamentary submissions by front organizations, corroborated by civil society respondents, and partially acknowledged by industry representatives during the dissemination meeting and in the media. We noted discrepancies and considered how different stakeholder interests fueled them. This analytical approach enabled examination of how institutional context and actor dynamics interacted to influence prioritization outcomes observed in the findings below.

Results

We present findings organized according to the domains of the Shiffman and Smith political prioritization framework, integrating evidence from interviews and document analysis [22]. Rather than reflecting isolated barriers, the results illustrate how transnational norms, domestic advocacy dynamics, and institutional features of Uganda’s political system interacted to shape policy attention towards health taxes on alcohol and SSBs. Table 4 summarizes key findings, while the narrative that follows contextualizes these dynamics within Uganda’s legislative and fiscal environment.

Table 4.

Summary of key results aligned to the Shiffman and Smith framework

Framework Domain	Component	Key Findings / Empirical Results	Implications for Health Tax Prioritization
Transnational Influence	Norm promotion	Global norms from UNGA resolutions, WHO NCD “best buys,” and the WHO 3-by-35 initiative increased awareness of health taxes. However, early omission of SSBs and EAC tax harmonization treaties constrained uptake in Uganda.	Norm diffusion raised visibility but did not translate into adoption due to regional constraints and delayed SSB prioritization.
	Industry response to global norms	Multinational alcohol and beverage companies expanded production, distribution, and acquisitions in Uganda, strengthening market power and countering health-tax proposals through economic framing.	Commercial actors effectively neutralized global health norms by aligning with national growth and investment agendas.
	Resource provision	Limited donor funding for alcohol and SSB taxation legislation facilitation constrained coordination, advocacy, and local evidence generation; technical assistance was largely limited to guidelines.	Lack of financial support weakened national capacity to advance legislation despite global technical guidance.
Domestic Advocacy	Policy community cohesion	Conflicting ministerial mandates fractured advocacy; while parliamentary and civil society coalitions emerged, industry lobbying undermined cohesion and diluted reforms.	Fragmented governance and industry interference stalled sustained advocacy for health taxes.
	Political entrepreneurship	Shifting bill sponsorship, bureaucratic delays, and withdrawal of champions weakened continuity; taxation clauses were removed following lobbying, leading to bill rejection.	Weak and inconsistent leadership prevented policy momentum and legislative success.
	Credible indicators	Policymakers questioned the lack of robust local evidence linking health taxes to reduced consumption and increased revenue.	Evidence gaps provided justification for resisting adoption of health taxes.
	Focusing events	The AIDS Trust Fund levy and annual excise amendments shifted attention toward revenue generation and voluntary contributions; donor funding cuts revived debate on domestic financing.	Focusing events redirected rather than consolidated support for dedicated health taxes.
	Clear policy alternatives	Dominant industrialization and investment priorities framed health taxes as misaligned with economic growth; public health legislation emphasized education over fiscal regulation.	Health taxes were perceived as politically less viable than existing revenue instruments.
National Political Environment	Political transition and institutions	Multiparty politics, party-line voting, high costs of private member’s bills, and transactional legislative processes disadvantaged health-tax proposals.	Parliamentary dynamics favored well-resourced actors and hindered passage of complex public-health fiscal reforms.
	Competing health priorities	Infectious diseases and maternal-child health dominated funding and attention; NCDs and unhealthy commodities remained underprioritized despite rising burden.	Competing priorities diluted political commitment to health taxes as NCD control tools.

Transnational influence

Results revealed that national debates over health taxes were strongly shaped by global norm promotion emphasizing the growing NCD burden and the effectiveness of fiscal measures to address it. Documentary analysis indicated that Uganda’s commitments under international frameworks, including United Nations resolutions tied to Sustainable Development Goal targets, contributed to agenda visibility by reinforcing expectations for national action on NCD prevention [12, 32]. These global commitments elevated awareness among policymakers but did not independently translate into policy adoption.

Norm promotion

At the United Nations General Assembly (UNGA), a vision emerged to address the global NCD burden [33]. Specifically, the document review revealed how the 2015 UNGA resolution 70/1 incorporated views from Heads of State and Government, including Uganda, who committed to developing ambitious national responses to implement Sustainable Development Goals (SDGs). This included SDG 3.4, which stipulates clear indicators focused on addressing the burden of NCDs [34]. Member states further reaffirmed, under resolution 73/2, their commitment to “strengthening the design and implementation of policies, including for resilient health systems to treat people living with NCDs while preventing and controlling their risk factors” [35].

Similarly, the WHO’s Global Action Plan for NCDs outlined 16 “best buys,” which were later extended through 2030, including three interventions targeting harmful alcohol use. However, early iterations notably omitted measures addressing excessive SSB consumption, leaving a policy gap for SSBs despite rising evidence and global concern worldwide [36]. Most recently, the WHO has spearheaded a 3 by 35 initiative, a global effort to increase the real prices of tobacco, alcohol, and SSBs by at least 50% by 2035 [37].

Similarly, WHO guidance on alcohol pricing and taxation provided technical legitimacy for fiscal interventions [38] such as the WHO-Parliamentary action guide on health taxes [39]. Respondents acknowledged that these resources informed domestic discourse, yet their influence was mediated by regional institutional constraints. Officials noted that obligations under East African Community tax-harmonization arrangements, which seek to align commodity taxation across member states, limited perceived national flexibility to adopt differentiated health-tax structures. In practice, these regional commitments shaped how policy options were evaluated within ministries responsible for trade and finance, constraining the translation of global norms into legislation, as revealed by a Ministry of Trade official in an illustrative quote below;

We have custom-related taxes and domestic-related taxes. Domestic taxes are the ones where you might very easily manipulate to achieve your policy objectives, whether they are in health or industrial development. Tariffs for international trade taxes are a major trade policy tool, and from the international trade perspective, the taxation that we do have is the custom duties. Most of the taxes we have are really high, but largely the drivers are not for health purposes. You find that it’s for the protection of domestic industry, and the policy objectives for raising such taxes are not to drive consumption to zero but rather to make it sensitive to the consumers.

At the same time, industry actors responded strategically to evolving global advocacy [40]. Document review showed expansion of multinational beverage production capacity and distribution networks in Uganda, reinforcing their economic embeddedness and strengthening their leverage in policy discussions [41]. Respondents across government and civil society described how industry narratives reframed taxation debates toward employment protection, investment promotion, and industrial growth themes that resonated strongly with Uganda’s neo-liberal development agenda centered on structural transformation and foreign direct investment.

Resource provision

Limited external financial support for advancing alcohol and SSB taxation debates emerged as a defining feature of Uganda’s experience. Stakeholders reported difficulty securing donor resources for advocacy, evidence generation, or legislative facilitation activities. One representative from Civil Society stated.

We are not finding donor support for adopting health taxes on alcohol-. Very few accept funding. So that is what we realized because we’re also disturbed. How come other ailments such as malaria, HIV, and tuberculosis are easily funded?

This highlights how donor prioritization patterns influenced national advocacy capacity. While technical assistance in the form of guidelines existed, respondents emphasized that advancing legislation required financial investment in consultations, lobbying, and policy analysis resources that were largely unavailable. As a result, momentum around health-tax promotion remained comparatively weak despite normative endorsement. Occasional capacity-building initiatives, such as an externally supported parliamentary learning visit to a delegation of MPs and their assistants to Sri Lanka in 2016 by Movendi International with support from partners including the World Bank to a capacity‑building trip were observed. It included visits to the Alcohol and Drug Information Center (ADIC), the National Authority on Tobacco and Alcohol (NATA), and workshops on alcohol policy on the margins of the “21st Century Alcohol Policy and Prevention Conference” [42]. Whereas such initiatives improved awareness, they did not compensate for the absence of sustained resourcing needed to shepherd legislation through Uganda’s complex policymaking process.

Domestic advocacy

Domestic advocacy in this context refers to the national-level factors that shape or undermine the promotion of a policy issue.

Policy community cohesion

Conflicting institutional mandates weakened cohesion within the policy community, particularly between revenue-oriented and health-oriented agencies. Respondents described how performance expectations tied to revenue generation often conflicted with public-health framing of excise duty reform. Respondents described how agencies frequently prioritized narrow sectoral objectives, limiting cross-sector alignment around fiscal interventions framed as health-promoting. A Ministry of Health respondent explained how revenue-generation priorities within fiscal agencies conflicted with preventive health framing:

When you talk of the Ministry of Trade, you also have the Uganda Revenue Authority. Sometimes it is a barrier to some of these efforts because they want to collect money and report the large amount of revenue they have collected. Sometimes they are a barrier.

This illustrates how performance metrics, which are embedded within institutional mandates, shaped engagement with tax reform proposals. Although coalitions such as the Parliamentary Forum on Noncommunicable Diseases sought to bridge sectoral divides, their influence was uneven and frequently countered by coordinated industry lobbying. One Civil Society representative argued,

We have several organs, especially in Parliament, that help us inform legislation. The Parliamentary Forum of Noncommunicable Diseases is an advocacy arm for us, and they are very quick in identifying any legislation that would probably affect them. They are also close to us in case there is legislation that we would want to move. They can support us in laying strategies or getting to the person concerned.

Respondents reported that industry actors sponsored stakeholder participation in consultations and emphasized economic contribution narratives to dilute reform proposals. For instance, another MoH representative said,

The industry influences some of our stakeholders; they sponsor some of our stakeholders to attend meetings and oppose our suggestions. They also reach those in the executive arm and convince them that, you know, we are going to lose taxes, we are going to lose jobs, many families are going to lose their livelihoods.

These dynamics contributed to episodic rather than sustained coalition-building, limiting policy momentum.

Political entrepreneurship

Political leadership for health taxes was inconsistent. Uganda’s legislative system allows individual parliamentarians to introduce private members’ bill proposals advanced without executive sponsorship and requiring independent mobilization of financial and technical resources. Respondents described how this institutional arrangement created vulnerability when policy champions withdrew or faced procedural barriers. One Parliamentary respondent recounted how responsibility for advancing alcohol-control legislation shifted across sponsors:

I came up with the bill, and the bill was presented before parliament, but unfortunately, the ugly side of our politics came in because I am from the opposition. The government side suspected that most probably I was trying sabotage the income. And then, of course, they even thought I would [gain political mileage] having moved such an act in parliament as a private member. So, the government side decided to take over the bill, and interestingly it bounced back as a private member’s bill again by the very person who was supposed to [have] handled it as a minister.

Subsequent reintroduction attempts encountered lobbying pressure and procedural objections. Tax provisions were ultimately removed prior to parliamentary debate, and the bill still failed to advance. These episodes illustrate how institutional complexity, resource requirements, and leadership discontinuity undermined sustained entrepreneurship necessary for policy prioritization.

Credible indicators

Stakeholders frequently highlighted perceived gaps in locally generated evidence demonstrating the revenue and behavioral impacts of health taxes. Although international evidence was widely cited, respondents reported that policymakers often questioned its applicability within Uganda’s economic and consumption context. As one representative of the Ministry of Health stated,

We have tried to talk to members of parliament and colleagues in trade, but somehow, we have not succeeded in convincing colleagues in trade that increasing taxes on alcohol and sugar-sweetened beverages would give more revenue and would discourage the consumption of those products.

This reflects how evidence credibility was socially constructed within policy processes. Absence of locally contextualized modelling weakened advocacy framing and justified resistance, reinforcing reliance on conventional excise duty adjustments rather than health-specific fiscal instruments.

Focusing events

Several policy events influenced agenda attention, though not always in ways that consolidated support for health taxes. Introduction of the AIDS Trust Fund levy in 2018 demonstrated the feasibility of commodity-based revenue mobilization, yet it simultaneously redirected attention toward earmarked financing for communicable diseases (HIV) rather than NCD prevention.

Following the enactment of the 2014 Excise Duty Act, Uganda’s revenue authority has routinely introduced amendment bills adjusting commodity levies through the annual budget cycle. While nominally informed by implementation experience, these revisions are predominantly shaped by fiscal imperatives, reflecting institutional incentives prioritizing domestic revenue mobilization over health evidence. The routinised amendment process has entrenched incremental, revenue-centred adjustment as the default policy pathway, structuring deliberation and narrowing consideration of health-oriented alternatives. Although some actors frame these revisions as indirectly affecting consumption, their policy logic largely reflects governance dynamics and power asymmetries influencing how evidence is interpreted and applied in taxation decisions, as revealed by one of the CSO respondents.

We go through the tax bills approach that happens every financial year; those are not regulatory taxes, although owing to public appeal, the minister of finance always alludes that in the interest of protecting the population, we have slapped a tax on alcohol of so much.

More recently, respondents identified reductions in external health-sector financing in 2025 following the January 20th U.S. Presidential signing of an executive order pausing foreign development assistance and the January 24th U.S. Secretary of State issuance of guidance requiring stop-work orders on existing foreign-assistance awards worldwide as a critical focusing event that revived discussion of domestic revenue strategies. This shift repositioned health taxes within broader fiscal sustainability debates, reflecting growing concern over maintaining health service provision amidst declining donor support. However, the emerging framing has predominantly centred around revenue stabilization rather than behavioral risk reduction, indicating that focusing events may alter policy salience without transforming underlying narratives shaping prioritization.

Clear policy alternatives

Uganda’s policy trajectory emphasizes a neoliberal, industrialization-led growth strategy focused on attracting foreign direct investment, transitioning from a subsistence to a cash economy, creating jobs, and maintaining investor-friendly tax regimes across government sectors. While the Third National Health Policy (2021) commits to exploring taxes on harmful commodities to strengthen health financing, the updated Public Health Act (2023) does not explicitly include NCD-related fiscal measures. As a result, some policymakers and stakeholders perceive health taxes as having a weaker legal and policy foundation than regulatory or health-promotion interventions. The Act instead prioritizes health promotion, awareness, and preventive approaches, which many public health actors consider insufficient for reducing consumption of unhealthy products. Within this context, dedicated health taxes appear misaligned with prevailing economic priorities and are perceived as a less viable policy alternative to existing revenue and investment strategies, thereby weakening momentum for fiscal instruments aimed at curbing NCD risks and strengthening sustainable health financing.

National political environment

The context within which the interaction of transnational influence and domestic advocacy occur influences the national political environment.

Political transition

The parliament is the arena for major policy debates, where contentious processes can advance or stifle health agendas. Uganda’s multiparty parliament is numerically dominated by National Resistance Movement (NRM) the ruling party. They first ran government effectively as a “no-party” or “single-party” system under the “Movement System” for nineteen years from 1986 up to 2005. Later it evolved into a political party since 2006 following the reintroduction of multiparty politics. The party’s internal caucus coordination often shapes legislative voting patterns and influences policy outcomes beyond formal debate processes on the parliamentary floor.

In Uganda’s legislative system, a private member’s bill is introduced by an individual parliamentarian without executive backing, placing responsibility for consultation, drafting, and political mobilization on the sponsor. Respondents highlighted the substantial resource demands of advocacy, noting that financing technical preparation and engagement activities often exceeds the capacity of health-sector actors. Indeed, when the Parliament ultimately declined to proceed with the alcohol control bill in August 2024, the reasons cited were its fiscal implications to government, an argument that undercut privately sponsored legislation lacking budget provisions and the capacity to resist complex reforms as echoed by the civil society respondent in the quote below:

A private member’s bill is expensive; we have had conversations with members of parliament asking us to support their private members’ bills. Therefore, in addition to money, these people are required to go through parliamentary processes. To be able to do the consultations and then draft and be able to come to parliament, we do not have such money to sponsor a private member’s bill.

These structural conditions advantaged better-resourced industry actors and contributed to repeated stagnation of reform efforts on all occasions the issue ascended into the legislative debates.

Competing health priorities

Finally, competition within Uganda’s health agenda limited sustained attention to fiscal measures targeting NCD risk factors. Respondents described how infectious diseases, maternal health, and under nutrition continued to dominate resource allocation and political discourse. Although recognition of NCD burden has increased, prioritization has lagged. Donor financing contraction has begun to elevate interest in domestic revenue options, yet commitment remains uneven and advocacy fragmented. Together, these dynamics illustrate how prioritization outcomes reflected not single barriers but interactions among fiscal pressures, institutional incentives, and political structures shaping Uganda’s policy environment. Taken together, these findings demonstrate that limited prioritization reflects systemic interactions rather than isolated constraints, a dynamic explored further in the discussion section that follows.

Discussion

This study highlights how Uganda’s evolving fiscal landscape shapes the political prioritization of health taxes on alcohol and SSBs. Similar to many low-, middle-, and high-income settings, health tax debates are influenced by both public health objectives and domestic revenue considerations. However, in Uganda, recent fiscal pressures associated with declining external assistance and growing domestic financing needs appear to have shifted the balance more strongly toward revenue-generation arguments. The contraction of donor financing in 2025 reinforced the strategic framing of health taxes as instruments for fiscal sustainability alongside NCD prevention. These findings suggest that political prioritization is dynamic and responsive to macro-fiscal conditions, underscoring the need for stronger public health advocacy and context-specific economic evidence to maintain health objectives within policy debates. Understanding Uganda’s experience therefore contributes to broader theorization of how health policy agendas evolve under conditions of aid transition and constrained fiscal sovereignty. The sections that follow, discuss and provide an interpretation and policy implications of the key findings in context.

Transnational Influence

First, global campaigns to increase awareness of the effectiveness of health taxes for reducing NCDs can have an impact. These global institutions have successfully embedded taxation of health-harming commodities within international NCD policy discourse thereby providing technical legitimacy and normative pressure for national adoption [12, 32, 36, 38]. However, these global campaigns do not necessarily resonate in every context. They ought to be locally adapted and framed for the context [43]. In Uganda’s case, despite strong support from WHO, the World Bank, and the United Nations, the adoption of health taxes legislation stalled under East African tax-harmonization constraints and coordinated industry opposition. Uganda’s unique set of regional agreements and political-economic incentives meant that legislation and implementation was limited [44] in part because commercial interests often trumped public health interests [45]. In other words, multinationals aligned market consolidation with economic-transformation goals, reframing debates to emphasize job creation, investment, and growth, thereby blunting public-health arguments for health taxes. These maneuvers add evidence of industry framing that resonates with political actors, undermining health-tax measures and implementation [46].

Cross-country research on health taxes in LMICs has shown how technical support from global entities can contribute to insulating policy processes from industry interference [47]. Similar observations have been reported in relation to countries achieving targets under the NCD countdown 2030 agenda [34]. Within the WHO European region, studies have noted industry influence limiting policy adoption [48]. This finding further aligns with emerging studies demonstrating that policy diffusion is filtered through national development agendas and regional governance architectures, particularly in politically integrated trade blocs [49].

Technical support mainly comprised of guidelines on taxing unhealthy commodities, whose impact was limited without financial resources to facilitate the legislative processes. Despite these useful technical instructions, resourcing legislative process advocacy, awareness, and local evidence generation to secure parliamentary approval was an enormous hurdle. Our findings suggest that the lack of dedicated funds to underwrite the legislative process activities likely contributed to low prioritization and stalled progress on Uganda’s legislative agenda during this period.

Failure to mobilize domestic funds for advancing health-tax legislation is both a cause and a consequence of its low political priority. After Parliament dropped the alcohol-control bill in August 2024, the government demonstrated little will to absorb fiscal implications of such a bill. This pattern mirrors other countries where health taxes hinges on country-specific financing mechanisms and regulatory frameworks capable of underwriting legislative processes and sustaining implementation over time in practice [50]. Elliott et al. (2020) similarly reported that effective health-tax design depends on robust local health and economic evidence plus coordinated interministerial support to navigate politics, align incentives, and sustain implementation [51].

Our findings further suggest that multinational firms derived influence not merely from lobbying but from their strategic integration into Uganda’s economic transformation agenda. By expanding production capacity, employment opportunities, and investment portfolios, these actors became embedded within national development priorities. This economic embeddedness enabled industry narratives to portray health taxes as threats to growth and competitiveness, increasing their resonance among trade, finance, and political actors and complicating adoption of public health-oriented fiscal reforms.

Domestic advocacy

Policy incoherence driven by conflicting ministerial mandates and weak intersectoral coordination also limited efforts to advance health taxes. Ministries pursued narrow sector goals that failed to generate sufficient support for health taxes. What appeared to be a lack of domestic advocacy was found to result from institutional fragmentation that hindered the formation of a coalition. Moreover, entrenched competition among critical sectors that shared similar goals, obscured political priorities. This mirrored environmental policy legislative experiences such as Uganda’s plastic-ban legislation, where sectoral divergence and misaligned incentives advantaged industry interests, thereby diluting regulatory ambition, and stalled health-promoting fiscal reforms [52].

Further still, the demands for additional local evidence as revealed from the findings should not be assumed to have been politically neutral. Research on the commercial determinants of health and corporate political activity has shown that calls for further context-specific evidence are frequently deployed in debates on tobacco, alcohol, and unhealthy food regulation to delay policy action and elevate evidentiary thresholds beyond those applied in other policy domains [53–55]. Our findings cannot determine whether requests for local modelling reflected genuine uncertainty, strategic resistance, or a combination of both. Nevertheless, the persistence of such demands despite extensive international evidence suggests that evidence requirements themselves may form part of the political contestation surrounding health taxes. This interpretation reinforces the need to view evidence not only as a technical input but also as a resource whose credibility and legitimacy are negotiated within broader power relations.

These findings also align with the corporate political activity literature, which demonstrates how commercial actors shape policy not only through direct lobbying but also through coalition management and strategic framing [56–58]. In Uganda, industry actors reportedly sponsored stakeholder participation in consultations and promoted narratives around employment, livelihoods, and tax revenue. Such practices broaden opposition beyond industry itself, creating the appearance of wider societal resistance while weakening cohesion among public health advocates and policymakers.

National political environment

The study demonstrates that policy entrepreneurship in fiscally complex domains is structurally resource intensive. Legislative sponsorship through private member mechanisms requires financial and technical mobilization that exceeds capacity of most health-sector actors, creating asymmetric advantage for commercially resourced stakeholders. Without financial sponsors, crucial measures such as alcohol control struggled to advance. Similar financial constraints have been reported elsewhere, underscoring how funding needs shape legislative momentum and policy outcomes, especially for public health taxation reforms requiring sustained shepherding through complex, prolonged parliamentary procedures [59]. This insight extends prioritization theory by emphasizing material resource asymmetries within legislative processes rather than focusing solely on actor leadership characteristics.

Viewed through a corporate political activity lens, these resource asymmetries represent an important mechanism through which commercial influence becomes institutionalized [48, 58]. Industry actors possess greater capacity to finance consultations, sustain legislative engagement, and navigate procedural requirements that accompany complex reforms. This advantage extends beyond lobbying individual decision-makers to shaping the rules and processes through which policies advance, thereby reinforcing structural barriers to health-promoting fiscal measures.

Evidence credibility and contextual legitimacy

Another key finding concerns the social construction of evidence credibility. While international research on health taxes is extensive, respondents repeatedly emphasized the absence of locally-grounded modelling of revenue and behavioral impacts. This suggests that policy acceptance depends less on evidence availability than on contextual legitimacy. In Uganda’s policymaking environment, locally generated fiscal projections appear to function as boundary objects bridging health and finance sectors. Their absence weakened persuasive framing and sustained reliance on conventional excise duty adjustments [60, 61].

Fiscal transition as agenda catalyst

The contraction of external health-sector financing in 2025 represented a critical contextual shift influencing prioritization dynamics. Reduced donor support elevated domestic revenue mobilization debates within the overall health financing policy discourse, reframing health taxes as fiscal instruments rather than purely preventive tools. This transition demonstrates how macro-fiscal shocks can act as focusing events reshaping agenda narratives and policy receptivity. The Ugandan experience contributes to broader understanding of health governance under aid transition, illustrating how financing transformations recalibrate policy incentives and reconfigure prioritization pathways.

This finding extends existing prioritization literature by demonstrating how external financing shocks can reshape the framing of policy solutions rather than merely increasing attention to existing problems. Whereas health-tax debates have traditionally been analyzed through NCD prevention and commercial determinants of health lenses, the Ugandan case illustrates how aid transition can reposition such policies within broader domestic financing and fiscal governance agendas. This suggests that political prioritization may be driven not only by changing evidence or actor coalitions, but also by shifts in the broader fiscal context that redefine the perceived purpose of policy instruments.

Beyond increasing agenda visibility, the aid-financing contraction fundamentally altered the political rationale through which health taxes were discussed. Prior to the financing shock, advocacy largely emphasized reducing harmful consumption and preventing NCDs. Following reductions in external assistance, however, debates increasingly centred on fiscal resilience, sustainability, and domestic revenue generation. This shift suggests that aid transition may not simply increase demand for new revenue sources; it can also transform the framing through which public-health policies gain political traction. Health taxes therefore became valued less for their preventive potential and more for their perceived contribution to maintaining health-sector financing amidst growing fiscal uncertainty.

What can be done to overcome industry influences?

Based on these findings, we recommend the following:

• Conduct more in-country and regional comparative research to better understand how health taxes can be framed in ways that resonate with policymakers and increase political feasibility [47].

• Strengthen technical and advocacy capacity to generate context-specific evidence that demonstrates both the health and fiscal benefits of alcohol and SSB taxation.

• Secure institutional sponsorship and dedicated resources for health tax legislation, recognizing the limitations of relying solely on private members’ bills.

• Build broad-based political support across parties and sectors to sustain momentum for health tax reforms and reduce vulnerability to political contestation.

• Establish mechanisms to protect legislators and policymaking processes from undue industry influence, thereby safeguarding transparent, evidence-informed decision-making and supporting the successful passage of health-focused fiscal measures.

Implications for policy

This research shines a light on how transnational influence may prove to be powerful. While WHO advocacy legitimized health taxes, East African Community harmonization requirements constrained national policy space a tension between regional economic integration and health sovereignty documented across African trade agreements [62]. Domestically, weak policy entrepreneurship was consequential. Unlike Kenya and Ethiopia’s tobacco control success, where coordinated civil society networks overcame industry opposition [63–65], Uganda’s health tax advocacy still lacks sustained coalition-building and strategic framing. Legislative resource constraints and transactional dynamics rendered health taxes vulnerable to industry influence, contrasting sharply with Togo and South Africa where politics enabled tobacco control progress despite similar barriers [66]. Thus, in Uganda, successful health tax adoption requires strategic navigation of regional constraints, durable advocacy coalitions, and understanding of legislative politics.

In the short term, the government should resource targeted technical assistance for Parliament and Ministries to translate health-tax norms from the WHO into locally credible evidence, accelerating informed debate and near-term legislative traction. At the same time, the government and civil society ought to formalize cross-sector advocacy platforms, finance sustained engagement and deploy counter-framing strategies to neutralize industry narratives and maintain momentum for health taxes. Finally, the Ugandan cabinet should harmonize inter-ministerial mandates and regional trade commitments, embedding health objectives within excise duty reforms to enable politically feasible, revenue-positive health tax adoption.

Conceptually, the findings suggest the need to extend prioritization frameworks toward greater incorporation of structural political economy variables. Legislative financing asymmetries, regional regulatory constraints, and donor transition dynamics operated not as background conditions but as active determinants shaping agenda evolution. Integrating these dimensions into analytical models may improve explanatory power when applied to fiscal instruments or other cross-sector policy domains.

Limitations

This study was not without limitations. First, the timing of data collection represents a limitation, as much of the empirical material reflects perspectives preceding or during the early stages of the 2025 external financing contraction. As fiscal restructuring continues, political positions and advocacy dynamics may evolve, meaning findings capture a transitional rather than settled policy landscape. Second, industry perspectives were underrepresented due to access barriers. Reliance on indirect sources, including media reports and accounts from other stakeholders, may not fully capture industry motivations and strategic decision-making. In addition, perspectives from industry-affiliated representative organizations may reflect strategic framing intended to advance commercial interests. To mitigate this risk, findings were triangulated with documentary evidence and interviews from government, civil society, and development partners; however, the possibility of selective disclosure cannot be fully excluded. Third, while the Shiffman and Smith framework provided a useful lens for examining policy prioritization, it does not explicitly theorize commercial determinants of health or the exercise of corporate political power. Consequently, some dimensions of industry influence may not have been fully captured. Fourth, the single-country focus may limit generalizability, although similar mechanisms may operate in comparable settings. Finally, the emphasis on elite policy actors may underrepresent public, consumer, and subnational perspectives.

Conclusion

More broadly, the study suggests that aid transition may create new pathways for policy attention by reframing health-promoting fiscal measures as instruments of fiscal sustainability, thereby linking debates on NCD prevention with wider domestic health financing agendas. The study further demonstrates that despite growing global endorsement and increasing fiscal pressures, health taxes on alcohol and sugar-sweetened beverages remain politically contested and weakly prioritized in Uganda. Their limited advancement reflects the interaction of fragmented institutional mandates, competing sectoral incentives, industry influence, regional policy constraints, and resource-intensive legislative processes that disadvantage public-health advocacy. Although the contraction of external health financing has renewed interest in domestic revenue mobilization, this shift has largely reframed health taxes as potential fiscal stabilization measures rather than established public-health priorities.

While health taxes are widely promoted internationally as effective instruments for both revenue generation and NCD prevention, the Ugandan case demonstrates that their political feasibility cannot be assumed. Rather, they remain an uncertain and evolving policy agenda whose future trajectory will depend on whether advocates can generate locally credible evidence, build cross-sector coalitions, align health and economic objectives, and navigate competing political and commercial interests. Uganda’s experience illustrates how the prioritization of health-promoting fiscal policies is shaped not by technical evidence alone but by broader political-economic conditions, offering important lessons for countries navigating aid transition, fiscal constraint, and growing commercial influence in health policymaking.

Abbreviations

ATF

AIDS Trust Fund

COREQ

Consolidated Criteria for Reporting Qualitative Results

CSO

Civil Society Organizations

FUE

Federation of Uganda Employers

FCTC

Framework Convention on Tobacco Control

MoH

Ministry of Health

MoFPED

Ministry of Finance, Planning and Economic Development

MoTIC

Ministry of Trade, Industry and Cooperatives

NCDs

Non-Communicable Diseases

SDGs

Sustainable development goals

SSBs

Sugar-Sweetened Beverages

UNGA

United Nations General Assembly

WHA

World Health Assembly

WHO

World Health Organization

Author contributions

ES, HZ, and FS conceived and designed the study. ES prepared the first draft. HZ, RS, KSL and ADK reviewed the manuscript. FS provided technical feedback. All the authors reviewed and approved the final manuscript.

Funding

This research study was part of a series of analytical country case studies on health policy analysis for health taxes supported by the WHO Alliance for Health Policy and Systems Research in collaboration with WHO departments and the Interagency Working Group on Health Taxes. The Alliance is supported by both core funding and project-specific designated funds; this work is supported by specified project funding from the government of Norway. The full list of Alliance donors is available here: https://ahpsr.who.int/about-us/funders.

Data availability

All data relevant to the study are included in the article.

Declarations

Ethics approval

Ethical approval was obtained from Makerere University SPHREC (Ref: SHP-2023-481) and the Uganda National Council for Science and Technology (Ref: HS3167ES). Administrative clearance was obtained from the participating institutions. Written informed consent was obtained from the participants before the interviews, and data protection guidelines were followed throughout the study.

Patient consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.