Questions/Answers

Thailand has many overweight children and adults. Thais aged 15 years and over who were overweight and obese increased from 34.7% in 2008 to 37.5% in 2014, who were at risk against Non-Communicable Diseases (NCDs) are the beginning of unhealthy, decreased productivity, appearance concern, low immunity and are at risk of having severe symptoms when infected with the coronavirus disease 2019 (COVID-19). In 2013, deaths from NCDs accounted for 82% of all deaths in Thailand. The government spends at least 4-500,000 Baht per year in caring for NCDs patients. In addition, obesity also causes a substantial economic loss in Thailand of 12,142.2 million Baht Sugar is a significant contributor to NCDs and obesity, with sugary drinks being the leading cause of excess sugar consumption. Beverages in Thailand have sugar content between 9-19 g/100 ml, while the recommendation is 6 g/100 ml. Moreover, 45.9% of Thai total indirect sugar consumption comes from sugary drinks, and the consumption behaviour of sweetened beverages tended to increase 31.6% from 2003 to 2009. In addition, the National Oral Health Survey found that 12-year-olds consumed more soft drinks/sweetened beverages steadily. This corresponds to an increase in the incidence of dental caries from 53.9% in 1994 to 57.3% in 2000. The above situation leads to cooperation with network partners to reduce the consumption of sugar-sweetened beverages among Thai people. This is the reason for establishing the Sugar Sweeten Beverages (SSBs) tax for good health and well-being of Thai people; and reducing the disparity in accessing healthy products for all people in the country.

This work is in line with the United Nations Public Service Awards (UNPSA) in enhancing the effectiveness of public institutions to reach the SDGs, as it collaborates with network partners in the public, private and non-governmental sectors to improve the health of the Thai population, access to healthier choice products. With this cooperation, there is a good relationship between all stakeholders, which can be enhanced to reach further goals for more sustainable development.

SSBs tax for good health and well-being of Thai people links to the United Nations Sustainable Development Goals (SDGs) in Goal 3, good health and well-being, and target 3.4, by 2030, reduce by one-third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being. Department of Health, Ministry of Public Health emphasis on health promotion and disease prevention throughout the life-course, had driven SSBs tax for good health and well-being of Thai people, which is the best buy policy that the World Health Organization recommends being effective in managing unhealthy diet which is risk factors for NCDs. SSBs tax was intended to decrease consumption by increasing the price of sugary drinks and was also meant to incentivize SSBs industry to reformulate their beverages. As a result, several healthier products have become relatively more affordable in the market. The availability of healthier products is shown to influence individual behaviours. Overall, some consumers may switch to healthier beverages with fewer sugars or no sugars content, which is expected to reduce the risk of NCDs and obesity.

SSBs tax is a signal to be aware of health. Health literacy would make people take care of their health, making sustainable in social terms. SSBs tax generates the government income. However, the economic situation must be considered. The tax rate was planned to increase every two years to allow the industry and people to adapt, making sustainable in economic terms. SSBs tax incentivizes manufacturers to reformulate their products resulting in more healthy beverages, which creates a healthy environment. Furthermore, a non-tax working group was formed to develop non-tax policies parallel with tax policy, making sustainable in environment terms.

Collaboration among network partners involved in public, private and non-governmental sectors cause efficiency and integrate policies in the same direction for the healthy population. By proposing the quick win of "prevention and control of food and nutrition health risk factors in the issue of taxation on sugary beverages" via the National Reform Steering Assembly of Thailand. The Network partners consist of academic sector (International Health Policy Program, Institute of Nutrition at Mahidol University, The Royal College Physicians of Thailand), government sector (Bureau of Dental Health and Bureau of Nutrition, Department of Health, Food and Drug Administration and the Fiscal Policy Office, Excise Department, Ministry of Finance) and civil society (Sweet Enough Network, Network of Fatless Belly Thais, Consumer Protection Network) The SSBs tax also resulted in a decrease in behaviour and amount of SSBs consumption. As a result, the risk of NCDs is reduced, and public health governance is more efficiently. In addition, the government income from beverages tax collection increased from 16,858 million Baht in 2017 to 24,969 million Baht in 2020, which can be used for further government services for Thai people.

One risk factor for NCDs is obesity. Thais have more abdominal obesity among women (14 million) than men (6.8 million). In addition, women have a higher proportion of diabetes than men, and 2 in 5 women with diabetes are reproductive-age women. Older pregnant women are at increased risk of hyperglycaemia. Socioeconomic inequalities put women at risk of diabetes from unhealthy diets. The SSBs tax measure will reduce gender inequality in health caused by problems with access to healthy products.

Establishment of SSBs tax causing benefits to Thai people as follows: 1. People have more choices for healthy products because beverage industry have reformulated their products to promote new low-sugar and healthier beverages to the market. 2. People have changed their behaviour to consume less sugary beverages. As a result, people switch from very sweet to fewer sugars or no sugars, not affecting their health. 3. Reduce the incidence of overweight and obesity and reduce the risk of NCDs. In addition, reducing the consumption of sugar, also reduces the prevalence of dental caries.

SSBs tax for good health and well-being of Thai people have been driven since 2009 as follows: 1. Review of the literature on SSBs tax in other countries. 2. Collect evidence in Thailand, including beverage consumption behaviour. The study found that Thai people consume more and more ready to drink beverages in all age groups. Furthermore, people will switch their behaviour when the price increases 20%. 3. Research on an economics study in price elasticity, including the impact on the economy and population. 4. Experts consultation to develop guidelines on SSBs tax collection in collaboration with academic network partners from the university, International Health Policy Program, the Fiscal Policy Office, and the Excise Department. To gather evidence and make policy proposals to the Ministry of Finance to enact legislation to tax sugar-sweeten beverages based on sugar content with a progressive rate, start at the beverages containing more than 6% of sugar. 5. Driving tax measures through the National Legislative Assembly in 2016 then entering the Cabinet before enacting the Act because SSBs tax is the fiscal measure that affects the overall population and the impact on the economy.

Thailand had to overcome several challenges along the way, especially opposition from the beverage industry. The industry indicated insufficient evidence to support a claim that the SSBs tax would reduce the intake of the SSBs among Thais. As a result, the taxation failed to be put forward at that time. Following the initial failure, the networks revisited previous efforts, funded research in the Thai context to support the argument. Additionally, invited international experts to share their experiences, knowledge and opinion on SSBs tax in the Thai context.

This is a policy innovation by the Bureau of Dental Health, Department of Health and network partners that have continuously driven SSBs tax in Thailand since 2009 in the 2nd National Health Assembly that endorsed the resolution of overweight and obesity management. In 2016, the National Reform Steering Assembly of Thailand voted on taxing sugary beverages beyond the health threshold. There has been a change in the excise tax rate under the new Excise Tax Act effected from September 16, 2017. The tax rate is based on the value and sugar content of non-alcoholic beverages.

The World Health Organization recommends SSBs tax as the best buy policy to manage obesity and NCDs risk factors. Many countries have adopted this concept to deal with health problems in their country. The reviewed literature shows the tax measure of food resulted in a change in consumption behaviour which is expected to reduce the incidence of obesity and diabetes. The most possible is the taxation of sugary drinks. Several countries have implemented the SSBs tax, such as Finland, France, Fiji, Mexico, Guatemala, Hungary, Norway, and some states in the United States.

Digital technology has been used in the establishment of SSBs tax for the good health and well-being of Thai people in 2 periods: 1. A database of beverages available in Thailand has been established during the policy-driven period, including the type, price and sugar content of the beverages. 2. Develop the FoodChoice application, a tool to educate nutrition by scanning the barcode from the products. Help people compare and decide to buy healthier products that increase in the market after the SSBs tax. This application would change consumer behaviour to healthier.

When Thailand enacted the SSBs tax, it drew the attention of countries in ASEAN, including Brunei, the Philippines, and Vietnam. In addition, at the regional level, Department of Health, Ministry of Public Health joined to develop the "framework on the development and implementation of fiscal measures on sweet beverages to promote health in ASEAN member states" under the ASEAN Health Cluster 1 (Promoting Healthy Lifestyle). The framework aims to encourage member states to use fiscal and commercial policies through SSBs tax in addressing risk factors and controlling NCDs. Internationally, the World Health Organization Thailand has nominated the Department of Health, Ministry of Public Health for the United Nations Inter-Agency Task Force Award (UNIATF Award) on the Prevention and Control of Non-communicable Diseases, in 2021, for the outstanding contribution to reducing sugar consumption in Thailand by leading a multisectoral action to tax sugar-sweetened beverages and setting an example on future pro-health taxes.

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The budget used for driving the SSBs tax for good health and well-being of Thai people is mainly the cost of meetings and mass communication through public media. The amount of money is 300,000 Baht annually for three years.

The three main factors for sustaining the project are 1. Network partners in public, private, academic sectors, and civil society that help contribute to the same goal 2. Industrial sector that adapts to the tax measure and the policy objectives to lower sugar content in drinks and generate the healthier choice of drinks for people 3. Public participation in developing a policy towards the goal, the health awareness and lesser consumption of sugar-sweeten beverages.

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A policy evaluation is planned by the assessment committee on the SSBs tax consists of academic groups, public organizations, and relevant civil society. The evaluation issues are as follows: 1. Adaptation of the beverage industry by the Excise Department, Ministry of Finance 2. Consumption behaviour and perceptions of Thai people after the SSBs tax by the Institute for Population and Social Research, Mahidol University 3. Health impacts and cost-effectiveness of the implementation of SSBs tax by the Food and Nutrition Policy for Health Promotion Program, International Health Policy Program

An output indicator is the adaptation of the beverage industry, which study from a survey of the price and quantity of sugar in beverages available in Thailand, divided into: 1. Changes in the price of SSBs 2. Changes in the proportion of SSBs An outcome indicator is consumption behaviour and perceptions of Thais, which study from the survey of consumption behaviour and perception, and the study of the average daily intake of sugar-sweeten beverages in the Thais aged six years and over, divided into: 1. Modification of the consumption behaviour of SSBs 2. Decreased consumption of sugar from beverages

Output indicators 1. Changes in the price of sugary drinks 12.7% increase in average SSBs prices as a domestic product. 2. Changes in the proportion of sugary drinks The proportion of low-sugar beverages was increased 14.4%. While the high-sugar beverages decreased, especially the beverages containing sugar 10-14 g/100 ml was significantly reduced (6.4%). Furthermore, there are an increase in "healthier choice" products. From 276 products before the SSBs tax to 1,053 products in February 2019, most of them are sugar-reduced products. Outcome indicators 1. Modification of the consumption behaviour of SSBs Consumption of SSBs decreased by 2.8% from 283.6 ml in 2018 to 275.8 ml in 2019, with the age group over 60 having the most significant decline. 2. Decreased consumption of sugar from beverages Thai people saw a decrease in sugar consumption from beverages by 15.3% and 14.0% in 2018 and 2019, respectively.

Policy formation and policy formulation started in 2009 through the 2nd National Health Assembly, with related network partners consisting of academic sector (International Health Policy Program, Institute of Nutrition at Mahidol University, The Royal College Physicians of Thailand), government sector (Bureau of Dental Health and Bureau of Nutrition, Department of Health, Food and Drug Administration and the Fiscal Policy Office, Excise Department, Ministry of Finance) and civil society (Sweet Enough Network, Network of Fatless Belly Thais, Consumer Protection Network) and in 2015, under the Commission on Public Health and Environment Reform Steering. The network proposed a quick win on "prevention and control of food and nutrition health risk factors in the issue of taxation of sugary beverages" through the National Reform Steering Assembly.

Stakeholders including academic sectors (International Health Policy Program, Institute of Nutrition Mahidol University, The Royal College Physicians of Thailand), government sector (Bureau of Dental Health and Bureau of Nutrition, Department of Health, Food and Drug Administration and the Fiscal Policy Office, Excise Department, Ministry of Finance) and civil society (Sweet Enough Network, Network of Fatless Belly Thais, Consumer Protection Network) have participated in driving the SSBs tax measure in policy formation and policy formulation process through the 2nd National Health Assembly in 2009. In 2015, the network proposed a quick win on "prevention and control of food and nutrition health risk factors in the issue of taxation of sugary beverages" through the National Reform Steering Assembly. The industrial sector help with the policy implementation process by adjusting with the changing excise tax rates and working together with the network partners to push non-tax policies and action plan. In the policy evaluation process, the SSBs tax evaluation committee, which consists of academic sectors, government sectors, and related civil society, plans and designs the evaluation.

This case study demonstrates that SSBs tax policy for good health and well-being is complicated, including various stakeholders with interests that sometimes conflict with policy goals, principally across health sector and the beverage industry. Effective inter-sectoral health initiatives across ministries, the financial sector, consumer protection, NGOs, and, most importantly, the political sector are required for successful implementation. In the policy-driven process of health promotion, multi-sector collaboration is critical. To make the operation more efficient and reduce the resistance from the industry, it is necessary to prepare in the following areas: 1. Information and evidence-based study that suit for the Thai context 2. The appropriate tax policy process 3. Clearly purpose of taxation is for the benefit of population health 4. Determine other non-tax policies along with tax measures 5. Communicating to build health literacy to the public This initiative could serve as a model for other health policies such as 1. Salt taxation 2. Non-tax policies to reduce Thai people's sugar intake 3. SSBs tax to prevent and control NCDs in ASEAN