ABSTRACT
Purpose: The unresolved crisis scenario and a prolonged COVID-19 pandemic increased social inequalities, mainly affecting the most vulnerable groups to access health services. The data in Pakistan show that health coverage benefits less than half of the population and a weak health system forces households to finance their health with out-of-pocket expenses. Therefore, it is a pending task to guarantee universal health coverage and design sustainable and inclusive policies to finance and provide health services. This study aims to offer a unique solution for health financing to Pakistan. Design/methodology/approach: This study uses the VECM model by employing the data from Pakistan to indicate sustainable policies for health financing. Finding(s): The results of this research show that direct taxes have a positive impact on public health expenditure;on the contrary, indirect taxes have a negative impact;it also confirms the importance of considering the direct tax based on high-income quintiles to guarantee equality and Access to health for all that contributes to human development. Practical implications: This article leads to the design of a new health system that will be useful for improving the health of Pakistan by presenting a solution to enhance health financing. Meanwhile, Pakistan will experience better conditions in the face of health crises. Social implications: Improving health financing through the equality approach can provide public access to the health system and strengthen the positive effects of the health system on socio-economic relations. Originality/value: This paper provides a unique solution for the ministry of health of Pakistan, International organisations and national authorities to reach a high level of health coverage without any cost to the financial system and increase the cost of living of the Pakistani people. Highlights: Increase efficient health financing by integrating health coverage programmes. Implementing direct taxes based on income quintiles improves health equality. Indirect tax policies will not positively contribute to health financing. Improving health financing efficiency decreases health inequality.Copyright © 2022, Emerald Publishing Limited.
ABSTRACT
BACKGROUND: Taxes on discretionary foods and sugar-sweetened beverages have emerged as a strategy for health promotion. Between 2018-2019, the Bermuda government introduced a phased tax on imported sugar-sweetened beverages, confectionery, products containing cocoa and pure sugar, and eliminated import duties on select healthy food items. The aim of this study was to conduct an mixed methods evaluation of perceptions of the tax among the general population and key stakeholders. METHODS: We conducted a survey of the general population (N = 400), and semi-structured interviews with key informants (N = 14) from the government, food and beverage, and health sectors to understand awareness, acceptability, and perceived impact of the tax after implementation. Survey data was analysed using thematic analysis, summary statistics, and Chi-squared tests. Key informant interviews were analysed using the framework method. RESULTS: General population respondents had high awareness of the sugar tax (94%) but low awareness of the healthy food subsidy (32%). Most respondents (67%) felt the tax was not an appropriate way to motivate healthier consumption due to beliefs the tax would not be effective (44%), and because of the high price of healthy food (20%). However, nearly half (48%) reported consuming fewer taxed products, primarily for health reasons but also motivated by price increases. Key informants indicated there was high awareness but limited understanding of the tax policy. Informants expressed support for taxation as a health promotion strategy, conditional on policy implementation. The lack of clear price differentiation between taxed and un-taxed products and the absence of accompanying health education were key factors believed to affect the impact of the tax. No informants were aware of use of tax revenues for health purposes and tax revenue was reportedly re-directed to other priorities after implementation. CONCLUSIONS: There was high awareness, but limited acceptability of the Bermuda sugar tax as implemented. Clarity in the tax policy, appropriateness of the tax mechanism, and use of revenue in alignment with the tax aim are critical components for acceptance. The absence of complementary education and health promotion affected acceptance and may limit potential health impacts. The lessons learned in Bermuda can inform similar policies in other settings.