Considerations for modelling a broad food tax in the Philippines and other low-income and middle-income countries.

Fiscal policies to improve diet are a promising strategy to address the increasing burden of non-communicable disease, the leading cause of death globally. Sugar-sweetened beverage taxes are the most implemented type of fiscal policy to improve diet. Yet taxes on food, if appropriately structured and applied across the food supply, may support a larger population-level shift towards a healthier diet. Designing these policies and guiding them through the legislative process requires evidence. Equity-oriented cost-effectiveness analyses that estimate the distribution of potential health and economic gains can provide this critical evidence. Taxes on less healthy foods are rarely modelled in low-income and middle-income countries.We describe considerations for modelling the effect of a food tax, which can provide guidance for food tax policy design. This includes describing issues related to the availability, reliability and level of detail of national data on dietary habits, the nutrient content of foods and food prices; the structure of the nutrient profile model; type of tax; tax rate; pass-through rate and price elasticity. Using the Philippines as an example, we discuss considerations for using existing data to model the potential effect of a tax, while also taking into account the political and food policy context. In this way, we provide a modelling framework that can help guide policy-makers and advocates in designing a food policy to improve the health and well-being of future generations in the Philippines and elsewhere.

Diarrheal disease, sanitation, and culture in India.

The health burden of childhood diarrhea in India has been a major public health concern. This study examines the role of the individualism-collectivism dichotomy in the prevalence of diarrhea in children under the age of five in India. Using subnational data on rice suitability to measure collectivism, we provide evidence that collectivism is negatively associated with the prevalence of childhood diarrhea across 618 Indian districts. We find that the mechanism works through improvements in water and sanitation. Collectivism propagates values of interdependence, cooperation and collective action which increases safe water and sanitation practices, thereby reducing the prevalence of diarrhea in children.

Syndemic thinking in large-scale studies: Case studies of disability, hypertension, and diabetes across income groups in India and China.

Syndemics consider where two or more conditions cluster, how they interact, and what macro-social processes have driven them together. Yet, syndemics emerge and interact differently across contexts and through time. This article considers how syndemics involving Type 2 diabetes (DM), disability, and income differ among men and women and between India and China. We use the WHO Study on global AGEing and adult health (SAGE) data. Using multivariable logistic regression, we assess the interaction of socio-economic factors and diseases on a multiplicative scale. We found that gender and income interact significantly in China to increase the odds of reporting hypertension and diabetes, but only for reporting diabetes in India. High income interacts with metabolic conditions to increase the odds of reporting comorbidity. Hypertension and diabetes were both independently and jointly associated with increase in the odds of being disabled in both countries, but the association varies by conditions. We argue that, first, our study reveals how these syndemics differ between countries and, second, that they differ significantly between income groups. Both findings refute the idea that a "global syndemic" exists. Instead, we emphasize the need for more ethnographic work that invests in local historical, social, and political interpretations of syndemics. Furthermore, ethnographic evidence suggests that the lowest-income communities face compounded social stress, untreated depression, and poor healthcare access alongside these clustered "metabolic" conditions. This point is most notable to demonstrate the need for chronic integrated care for not only the wealthy but also poorer people with metabolic conditions.

Clinical and economic burden of diabetic foot ulcers: A 5-year longitudinal multi-ethnic cohort study from the tropics.

Diabetic foot ulcers (DFUs) present a substantial clinical and economic burden to healthcare systems around the world, with significant reductions in quality of life for those affected. We aimed to analyse the clinical and economic burden of DFU via a 5-year longitudinal multi-ethnic cohort study. A longitudinal analysis of inpatient and outpatient DFUs data over 5 years from a university tertiary hospital in Singapore was performed. Data included baseline characteristics, clinical outcomes, hospitalisation, and outpatient details. Descriptive statistics, Kaplan-Meier survival analyses, and Cox proportional hazard models were performed. Patients treated for DFUs (n = 1729, mean patient age of 63·4 years) were assessed. The cohort consists of Chinese (61.4%), Malay (13.5%), and Indian (18.4%) patients. Common comorbidities included peripheral arterial disease (74.8%), peripheral neuropathy (14.5%), and a median haemoglobin A1c of 9.9%. Patients underwent toe(s) amputation (36.4%), transmetatarsal amputations (16.9%), or major amputations (6·5%). The mean length of inpatient stay for ulcer-only, minor amputation, and major amputation was 13.3, 20.5, and 59.6 days, respectively. Mean cost per patient-year was US $3368 (ulcer-only), US $10468 (minor amputation), and US $30131 (major amputation). Minor amputation-free survival was 80.9% at 1 year and 56.9% at 5 years, while major amputation-free survival was 97.4% at 1 year and 91.0% at 5 years. In conclusion, within our multi-ethnic cohort of patients from the tropics, there was significant clinical and economic burden of DFUs, with a high wound per patient ratio and escalating healthcare costs corresponding to more proximal amputation levels.

The distributional impact of taxing sugar-sweetened beverages: findings from an extended cost-effectiveness analysis in South Africa.

BACKGROUND: Facing increasing obesity prevalence and obesity-related disease burden, South Africa has devised an obesity prevention strategy that includes a recently implemented tax on the sugar content of sugar-sweetened beverages (SSB). We assess the potential distributional impact (across socioeconomic groups) of this tax on type 2 diabetes mellitus (T2DM) incidence and associated mortality and its financial burden on households. METHODS: We conducted an extended cost-effectiveness analysis of the new 10% tax on SSBs in South Africa, and estimated: the averted premature deaths related to T2DM, the financial benefits to households (out-of-pocket (OOP) medical costs and indirect costs due to productivity losses averted), the increased government tax revenues and healthcare savings for the government, all across income quintiles. FINDINGS: A 10% SSB tax increase would avert an estimated 8000 T2DM-related premature deaths over 20 years, with most deaths averted among the third and fourth income quintiles. The government would save about South African rand (ZAR) 2 billion (US$140 million) in subsidised healthcare over 20 years; and would raise ZAR6 billion (US$450 million) in tax revenues per annum. The bottom two quintiles would bear the smallest tax burden increase (36% of the additional taxes). The bottom two income quintiles would also have the lowest savings in OOP payments due to significant subsidisation provided by government healthcare. Lastly, an estimated 32 000 T2DM-related cases of catastrophic expenditures and 12 000 cases of poverty would be averted. CONCLUSIONS: SSB taxation would have a substantial distributional impact on obesity-related premature deaths, cost savings to the government and the financial outcomes of South Africa's population.

Modelling the impact of a tax on sweetened beverages in the Philippines: an extended cost-effectiveness analysis.

OBJECTIVE: To assess the potential impact of a new tax on sweetened beverages on premature deaths associated with noncommunicable diseases in the Philippines. METHODS: In January 2018, the Philippines began imposing a tax of 6 Philippine pesos per litre (around 13%) on sweetened beverages to curb the obesity burden. Using national data sources, we conducted an extended cost-effectiveness analysis to estimate the effect of the tax on the numbers of premature deaths averted attributed to type 2 diabetes mellitus, ischaemic heart disease and stroke, across income quintiles over the period 2018-2037. We also estimated the financial benefits of the tax from reductions in out-of-pocket payments, direct medical costs averted and government health-care cost savings. FINDINGS: The tax could avert an estimated 5913 deaths related to diabetes, 10 339 deaths from ischaemic heart disease and 7950 deaths from stroke over 20 years. The largest number of deaths averted could be among the fourth and fifth (highest) income quintiles. The tax could generate total health-care savings of 31.6 billion Philippine pesos (627 million United States dollars, US$) over 20 years, and raise 41.0 billion Philippine pesos (US$ 813 million) in revenue per annum. The poorest quintile could bear the smallest tax burden increase (14% of the additional tax; 5.6 billion Philippine pesos) and have the lowest savings in out-of-pocket payments due to relatively large health-care subsidies. Finally, we estimated that 13 890 cases of catastrophic expenditure could be averted. CONCLUSION: The new sweetened beverage tax may help to reduce obesity-related premature deaths and improve financial well-being in the Philippines.

Distributional health and financial benefits of increased tobacco taxes in Colombia: results from a modelling study.

BACKGROUND: In Colombia, smoking is the second leading modifiable risk factor for premature mortality. In December 2016, Colombia passed a major tax increase on tobacco products in an effort to decrease smoking and improve population health. While tobacco taxes are known to be highly effective in reducing the prevalence of smoking, they are often criticised as being regressive in consumption. This analysis attempts to assess the distributional impact (across socioeconomic groups) of the new tax on selected health and financial outcomes. METHODS: This study builds on extended cost-effectiveness analysis methods to study the new tobacco tax in Colombia, and estimates, over a time period of 20 years and across income quintiles of the current urban population (80% of the country population), the years of life gained with smoking cessation and the increased tax revenues, all associated with a 70% relative price increase of the pack of cigarettes. Where possible, we use parameters that vary by income quintile, including price elasticity of demand for cigarettes (average of -0.44 estimated from household survey data). FINDINGS: Over 20 years, the tax increase would lead to an estimated 191 000 years of life gained among Colombia's current urban population, with the largest gains among the bottom two income quintiles. The additional annual tax revenues raised would amount to about 2%-4% of Colombia's annual government health expenditure, with the poorest quintiles bearing the smallest tax burden increase. CONCLUSIONS: The tobacco tax increase passed by Colombia has substantial implications for the country's population health and financial well-being, with large benefits likely to accrue to the two poorest quintiles of the population.

Macroeconomic Effects of Medicare.

This paper develops an overlapping generations model to study the macroeconomic effects of an un-expected elimination of Medicare. We find that a large share of the elderly respond by substituting Medicaid for Medicare. Consequently, the government saves only 46 cents for every dollar cut in Medicare spending. We argue that a comparison of steady states is insufficient to evaluate the welfare effects of the reform. In particular, we find lower ex-ante welfare gains from eliminating Medicare when we account for the costs of transition. Lastly, we find that a majority of the current population benefits from the reform but that aggregate welfare, measured as the dollar value of the sum of wealth equivalent variations, is higher with Medicare.

The Macroeconomic and Welfare Implications of Rural Health Insurance and Pension Reforms in China.

We assess the potential impact of rural health insurance and pension reforms on macroeconomic outcomes and social welfare in a dynamic general equilibrium model calibrated to the Chinese economy. We analyze transition paths as well as steady state responses to the new policies. The current reforms in China provide modest rural pensions and reimbursement of a portion of healthcare costs, but at rates that are substantially lower than are already in place in the urban sector. We investigate the potential effect of raising the rural benefit rates to those enjoyed in the urban sector. While both reforms reduce income per capita, we show that the health insurance reforms are potentially welfare improving if they are implemented in a way that leads to reduced out-of-pocket health spending. The welfare gains are driven by rural health insurance providing relief from the risk of catastrophic medical expenditures that can wipe out household savings and force long working hours. A pay-as-you-go rural pension results in a welfare gain in the short-run but welfare loss in the long-run due to the distorting effects of taxes. Despite an increase in required financing due to an aging population, the welfare impact of rural health insurance remains positive when incorporating the projected old-age dependency ratio for the year 2050. However, a pay-as-you-go rural pension creates large income and welfare losses with 2050 demographics.