Políticas fiscales como herramienta para la prevención de sobrepeso y obesidad

One of three adults in Mexico is obese, therefore, policies to reduce overweight and obesity prevalence in the country were designed. The use of fiscal policy was proposed as a way to discourage the consumption of soft drinks and raise funds to pay health services used by obese patients. The aim of this chapter, published in 2012, was to open the debate on the use of fiscal policy as a tool for the prevention of overweight and obesity in Mexico. Arguments for and against fiscal policies are discussed and outlined. The case of the soft drinks market is examined and the challenges for the design and implementation of a tax policy are discussed. The evidence presented in this chapter shows that tax policies are just one of the many tools that can be used to modify the consumption of unhealthy foods and beverages. However, its effect is limited if not accompanied by other measures, such as improving access and availability of healthy goods, advertising, and product labeling

Efectos heterogéneos en la demanda ante un impuesto al refresco en México

The increasing burden of obesity and related non-communicable diseases in the world has encouraged the design of effective policies in order to contain this trend. Excise taxes on low-nutritious food and sugar-sweetened beverages consumption, such as soft-drinks, have been proposed. Currently, a growing number of studies have calculated potential effects of soft-drinks taxes considering data for average consumers, and have assessed effectiveness of such measure on raising fresh revenues to the government, modifying consumption patterns, and population weight reduction. Nevertheless, there is evidence of heterogeneity of the demand of soft-drinks related to poverty and the level of consumption of soft-drinks. It has also been emphasised the need of examining the possible distributional effects of an excise tax in populations with uneven income distribution. We used Mexican data to discuss effectiveness and equity implications of an excise tax on soft-drinks consumption in populations with heterogeneous demand. We estimated the changes in the quantity purchased and household monthly expenditure on soft-drinks of 8434 households that answered the 2005 Mexican Family Life Survey. Specific price elasticities of the demand for soft-drinks of households grouped by their level of consumption (low, medium and high) and poverty (extreme, moderate and income superior to moderate poverty) were used. Several excise tax rate scenarios were considered: from a conservative level (tax rate: t=20%), to a least conservative level (t=65%) that was defined by the longitudinal analysis of body mass index changes in adults between 2002 and 2005. Effectiveness was evaluated by revenue collection (as a proportion of the cost of a comprehensive obesity prevention strategy), changes of the patterns of consumption and changes in calories related to changes of body mass index. Equity was assessed by concentration curves and indexes of the distribution of tax burden and the distribution of changes of the proportion of food expenditure devoted to soft-drink purchasing. The results suggest although revenues collected with low tax rates (20%) could partially finance a comprehensive obesity prevention strategy for Mexico, effectiveness on changing the patterns of consumption is only observable at tax rates higher than 45%. An excise tax is not effective on modifying population body mass index if tax rates are lower than 65%. Despite the fact that effects are concentrated in high consumption households, regressiveness is a latent problem due to the high tax burden imposed to households on extreme poverty. These results are different from the ones calculated in previous exercises in Mexico, considering average consumers. If governments are considering excise taxes on soft drinks to prevent obesity, heterogeneity of the demand for soft-drinks due to poverty and consumption level should be considered, especially in emergent economies with uneven income distribution. For the Mexican case, in order to design policies that adequately affect the demand for soft drinks, tax rates superior to 45% are recommended, along with redistributional mechanisms to promote equity by compensating households in extreme and moderate poverty, and effective interventions to reduce population weight

Efectos heterogéneos en la demanda ante un impuesto al refresco en México

The increasing burden of obesity and related non-communicable diseases in the world has encouraged the design of effective policies in order to contain this trend. Excise taxes on low-nutritious food and sugar-sweetened beverages consumption, such as soft-drinks, have been proposed. Currently, a growing number of studies have calculated potential effects of soft-drinks taxes considering data for average consumers, and have assessed effectiveness of such measure on raising fresh revenues to the government, modifying consumption patterns, and population weight reduction. Nevertheless, there is evidence of heterogeneity of the demand of soft-drinks related to poverty and the level of consumption of soft-drinks. It has also been emphasised the need of examining the possible distributional effects of an excise tax in populations with uneven income distribution. We used Mexican data to discuss effectiveness and equity implications of an excise tax on soft-drinks consumption in populations with heterogeneous demand. We estimated the changes in the quantity purchased and household monthly expenditure on soft-drinks of 8434 households that answered the 2005 Mexican Family Life Survey. Specific price elasticities of the demand for soft-drinks of households grouped by their level of consumption (low, medium and high) and poverty (extreme, moderate and income superior to moderate poverty) were used. Several excise tax rate scenarios were considered: from a conservative level (tax rate: t=20%), to a least conservative level (t=65%) that was defined by the longitudinal analysis of body mass index changes in adults between 2002 and 2005. Effectiveness was evaluated by revenue collection (as a proportion of the cost of a comprehensive obesity prevention strategy), changes of the patterns of consumption and changes in calories related to changes of body mass index. Equity was assessed by concentration curves and indexes of the distribution of tax burden and the distribution of changes of the proportion of food expenditure devoted to soft-drink purchasing. The results suggest although revenues collected with low tax rates (20%) could partially finance a comprehensive obesity prevention strategy for Mexico, effectiveness on changing the patterns of consumption is only observable at tax rates higher than 45%. An excise tax is not effective on modifying population body mass index if tax rates are lower than 65%. Despite the fact that effects are concentrated in high consumption households, regressiveness is a latent problem due to the high tax burden imposed to households on extreme poverty. These results are different from the ones calculated in previous exercises in Mexico, considering average consumers. If governments are considering excise taxes on soft drinks to prevent obesity, heterogeneity of the demand for soft-drinks due to poverty and consumption level should be considered, especially in emergent economies with uneven income distribution. For the Mexican case, in order to design policies that adequately affect the demand for soft drinks, tax rates superior to 45% are recommended, along with redistributional mechanisms to promote equity by compensating households in extreme and moderate poverty, and effective interventions to reduce population weight

Understanding the heterogeneous nature of the demand for soft drinks in Mexico: why social determinants also matter.

Background. Soft drink consumption is a risk factor for obesity and non-communicable chronic diseases, and policies to reduce it have been proposed around the world, including taxation. Little is known about the role of other social and economic factors on the demand of such goods. In addition, heterogeneity of the demand due to different levels of consumption has been rarely explored. The aim of this study is to analyse the heterogeneous nature of the demand for soft drinks to understand the role of economic and social factors (provision of safe water /local food market conditions) and draw recommendations for the design of obesity prevention. Methods. Population, cross-sectional analysis of household data from the Mexican Family Life Survey, grouped into three consumption groups (low/medium/high consumers, defined by the proportion of total household expenditure devoted to soft drink purchases) and three economic poverty groups (defined by extreme and moderate income poverty lines). Multivariate probit regressions were applied to explore factors associated to the probability to be a consumer, and simultaneous multivariate quantile regressions were used to model the quantity purchased of soft drinks. Heckman’s procedure was used to control for identification bias. Results. The adjusted probability that a household becomes a consumer is significantly higher with male, educated heads of households and higher household income. Living in localities where access to safe water for drinking and cooking needs is not universal significantly increases the probability to consume soft drinks while living in localities with convenience stores and supermarkets (local food market condition) significantly decreases it, especially in households facing extreme poverty. Demand from low-consumption households is price-inelastic (-0.97) compared with high-consumers (-1.2). Yet when the population is grouped by poverty, households in extreme poverty have a higher significant price-elasticity (-1.5) than those above moderate poverty line (-1.3). Conclusions. In order to design policies that adequately affect the demand for soft drinks on high consumers and benefit the poor, social factors should be considered. A comprehensive obesity prevention strategy should complement taxes with policies that affect social determinants such as the local provision of safe water and local food market conditions

Estimating mortality and disability in Peru before the COVID-19 pandemic: a systematic analysis from the Global Burden of the Disease Study 2019

"Background: Estimating and analyzing trends and patterns of health loss are essential to promote efficient resource allocation and improve Peru’s healthcare system performance. Methods: Using estimates from the Global Burden of Disease (GBD), Injuries, and Risk Factors Study (2019), we assessed mortality and disability in Peru from 1990 to 2019. We report demographic and epidemiologic trends in terms of population, life expectancy at birth (LE), mortality, incidence, prevalence, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) caused by the major diseases and risk factors in Peru. Finally, we compared Peru with 16 countries in the Latin American (LA) region. Results: The Peruvian population reached 33.9 million inhabitants (49.9% women) in 2019. From 1990 to 2019, LE at birth increased from 69.2 (95% uncertainty interval 67.8–70.3) to 80.3 (77.2–83.2) years. This increase was driven by the decline in under-5 mortality (−80.7%) and mortality from infectious diseases in older age groups (+60 years old). The number of DALYs in 1990 was 9.2 million (8.5–10.1) and reached 7.5 million (6.1–9.0) in 2019. The proportion of DALYs due to non-communicable diseases (NCDs) increased from 38.2% in 1990 to 67.9% in 2019. The all-ages and age-standardized DALYs rates and YLLs rates decreased, but YLDs rates remained constant. In 2019, the leading causes of DALYs were neonatal disorders, lower respiratory infections (LRIs), ischemic heart disease, road injuries, and low back pain. The leading risk factors associated with DALYs in 2019 were undernutrition, high body mass index, high fasting plasma glucose, and air pollution. Before the COVID-19 pandemic, Peru experienced one of the highest LRIs-DALYs rates in the LA region. Conclusion: In the last three decades, Peru experienced significant improvements in LE and child survival and an increase in the burden of NCDs and associated disability. The Peruvian healthcare system must be redesigned to respond to this epidemiological transition. The new design should aim to reduce premature deaths and maintain healthy longevity, focusing on effective coverage and treatment of NCDs and reducing and managing the related disability.

Future and potential spending on health 2015-40 : development assistance for health, and government, prepaid private, and out-of-pocket health spending in 184 countries

Background The amount of resources, particularly prepaid resources, available for health can affect access to health care and health outcomes. Although health spending tends to increase with economic development, tremendous variation exists among health financing systems. Estimates of future spending can be beneficial for policy makers and planners, and can identify financing gaps. In this study, we estimate future gross domestic product (GDP), all-sector government spending, and health spending disaggregated by source, and we compare expected future spending to potential future spending. Methods We extracted GDP, government spending in 184 countries from 1980-2015, and health spend data from 1995-2014. We used a series of ensemble models to estimate future GDP, all-sector government spending, development assistance for health, and government, out-of-pocket, and prepaid private health spending through 2040. We used frontier analyses to identify patterns exhibited by the countries that dedicate the most funding to health, and used these frontiers to estimate potential health spending for each low-income or middle-income country. All estimates are inflation and purchasing power adjusted. Findings We estimated that global spending on health will increase from US$9.21 trillion in 2014 to$24.24 trillion (uncertainty interval [UI] 20.47-29.72) in 2040. We expect per capita health spending to increase fastest in upper-middle-income countries, at 5.3% (UI 4.1-6.8) per year. This growth is driven by continued growth in GDP, government spending, and government health spending. Lower-middle income countries are expected to grow at 4.2% (3.8-4.9). High-income countries are expected to grow at 2.1% (UI 1.8-2.4) and low-income countries are expected to grow at 1.8% (1.0-2.8). Despite this growth, health spending per capita in low-income countries is expected to remain low, at $154 (UI 133-181) per capita in 2030 and$195 (157-258) per capita in 2040. Increases in national health spending to reach the level of the countries who spend the most on health, relative to their level of economic development, would mean $321 (157-258) per capita was available for health in 2040 in low-income countries. Interpretation Health spending is associated with economic development but past trends and relationships suggest that spending will remain variable, and low in some low-resource settings. Policy change could lead to increased health spending, although for the poorest countries external support might remain essential.Peer reviewe

Future and potential spending on health 2015-40: Development assistance for health, and government, prepaid private, and out-of-pocket health spending in 184 countries

Background: The amount of resources, particularly prepaid resources, available for health can affect access to health care and health outcomes. Although health spending tends to increase with economic development, tremendous variation exists among health financing systems. Estimates of future spending can be beneficial for policy makers and planners, and can identify financing gaps. In this study, we estimate future gross domestic product (GDP), all-sector government spending, and health spending disaggregated by source, and we compare expected future spending to potential future spending. Methods: We extracted GDP, government spending in 184 countries from 1980-2015, and health spend data from 1995-2014. We used a series of ensemble models to estimate future GDP, all-sector government spending, development assistance for health, and government, out-of-pocket, and prepaid private health spending through 2040. We used frontier analyses to identify patterns exhibited by the countries that dedicate the most funding to health, and used these frontiers to estimate potential health spending for each low-income or middle-income country. All estimates are inflation and purchasing power adjusted. Findings: We estimated that global spending on health will increase from US$9.21 trillion in 2014 to$24.24 trillion (uncertainty interval [UI] 20.47-29.72) in 2040. We expect per capita health spending to increase fastest in upper-middle-income countries, at 5.3% (UI 4.1-6.8) per year. This growth is driven by continued growth in GDP, government spending, and government health spending. Lower-middle income countries are expected to grow at 4.2% (3.8-4.9). High-income countries are expected to grow at 2.1% (UI 1.8-2.4) and low-income countries are expected to grow at 1.8% (1.0-2.8). Despite this growth, health spending per capita in low-income countries is expected to remain low, at $154 (UI 133-181) per capita in 2030 and$195 (157-258) per capita in 2040. Increases in national health spending to reach the level of the countries who spend the most on health, relative to their level of economic development, would mean $321 (157-258) per capita was available for health in 2040 in low-income countries. Interpretation: Health spending is associated with economic development but past trends and relationships suggest that spending will remain variable, and low in some low-resource settings. Policy change could lead to increased health spending, although for the poorest countries external support might remain essential

Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks for 195 countries and territories, 1990–2017 : a systematic analysis for the Global Burden of Disease Study 2017

Background: The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017 comparative risk assessment (CRA) is a comprehensive approach to risk factor quantification that offers a useful tool for synthesising evidence on risks and risk outcome associations. With each annual GBD study, we update the GBD CRA to incorporate improved methods, new risks and risk outcome pairs, and new data on risk exposure levels and risk outcome associations. Methods: We used the CRA framework developed for previous iterations of GBD to estimate levels and trends in exposure, attributable deaths, and attributable disability-adjusted life-years (DALYs), by age group, sex, year, and location for 84 behavioural, environmental and occupational, and metabolic risks or groups of risks from 1990 to 2017. This study included 476 risk outcome pairs that met the GBD study criteria for convincing or probable evidence of causation. We extracted relative risk and exposure estimates from 46 749 randomised controlled trials, cohort studies, household surveys, census data, satellite data, and other sources. We used statistical models to pool data, adjust for bias, and incorporate covariates. Using the counterfactual scenario of theoretical minimum risk exposure level (TMREL), we estimated the portion of deaths and DALYs that could be attributed to a given risk. We explored the relationship between development and risk exposure by modelling the relationship between the Socio-demographic Index (SDI) and risk-weighted exposure prevalence and estimated expected levels of exposure and risk-attributable burden by SDI. Finally, we explored temporal changes in risk-attributable DALYs by decomposing those changes into six main component drivers of change as follows: (1) population growth; (2) changes in population age structures; (3) changes in exposure to environmental and occupational risks; (4) changes in exposure to behavioural risks; (5) changes in exposure to metabolic risks; and (6) changes due to all other factors, approximated as the risk-deleted death and DALY rates, where the risk-deleted rate is the rate that would be observed had we reduced the exposure levels to the TMREL for all risk factors included in GBD 2017. Findings: In 2017,34.1 million (95% uncertainty interval [UI] 33.3-35.0) deaths and 121 billion (144-1.28) DALYs were attributable to GBD risk factors. Globally, 61.0% (59.6-62.4) of deaths and 48.3% (46.3-50.2) of DALYs were attributed to the GBD 2017 risk factors. When ranked by risk-attributable DALYs, high systolic blood pressure (SBP) was the leading risk factor, accounting for 10.4 million (9.39-11.5) deaths and 218 million (198-237) DALYs, followed by smoking (7.10 million [6.83-7.37] deaths and 182 million [173-193] DALYs), high fasting plasma glucose (6.53 million [5.23-8.23] deaths and 171 million [144-201] DALYs), high body-mass index (BMI; 4.72 million [2.99-6.70] deaths and 148 million [98.6-202] DALYs), and short gestation for birthweight (1.43 million [1.36-1.51] deaths and 139 million [131-147] DALYs). In total, risk-attributable DALYs declined by 4.9% (3.3-6.5) between 2007 and 2017. In the absence of demographic changes (ie, population growth and ageing), changes in risk exposure and risk-deleted DALYs would have led to a 23.5% decline in DALYs during that period. Conversely, in the absence of changes in risk exposure and risk-deleted DALYs, demographic changes would have led to an 18.6% increase in DALYs during that period. The ratios of observed risk exposure levels to exposure levels expected based on SDI (O/E ratios) increased globally for unsafe drinking water and household air pollution between 1990 and 2017. This result suggests that development is occurring more rapidly than are changes in the underlying risk structure in a population. Conversely, nearly universal declines in O/E ratios for smoking and alcohol use indicate that, for a given SDI, exposure to these risks is declining. In 2017, the leading Level 4 risk factor for age-standardised DALY rates was high SBP in four super-regions: central Europe, eastern Europe, and central Asia; north Africa and Middle East; south Asia; and southeast Asia, east Asia, and Oceania. The leading risk factor in the high-income super-region was smoking, in Latin America and Caribbean was high BMI, and in sub-Saharan Africa was unsafe sex. O/E ratios for unsafe sex in sub-Saharan Africa were notably high, and those for alcohol use in north Africa and the Middle East were notably low. Interpretation: By quantifying levels and trends in exposures to risk factors and the resulting disease burden, this assessment offers insight into where past policy and programme efforts might have been successful and highlights current priorities for public health action. Decreases in behavioural, environmental, and occupational risks have largely offset the effects of population growth and ageing, in relation to trends in absolute burden. Conversely, the combination of increasing metabolic risks and population ageing will probably continue to drive the increasing trends in non-communicable diseases at the global level, which presents both a public health challenge and opportunity. We see considerable spatiotemporal heterogeneity in levels of risk exposure and risk-attributable burden. Although levels of development underlie some of this heterogeneity, O/E ratios show risks for which countries are overperforming or underperforming relative to their level of development. As such, these ratios provide a benchmarking tool to help to focus local decision making. Our findings reinforce the importance of both risk exposure monitoring and epidemiological research to assess causal connections between risks and health outcomes, and they highlight the usefulness of the GBD study in synthesising data to draw comprehensive and robust conclusions that help to inform good policy and strategic health planning

Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019

Background: In an era of shifting global agendas and expanded emphasis on non-communicable diseases and injuries along with communicable diseases, sound evidence on trends by cause at the national level is essential. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) provides a systematic scientific assessment of published, publicly available, and contributed data on incidence, prevalence, and mortality for a mutually exclusive and collectively exhaustive list of diseases and injuries. Methods: GBD estimates incidence, prevalence, mortality, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) due to 369 diseases and injuries, for two sexes, and for 204 countries and territories. Input data were extracted from censuses, household surveys, civil registration and vital statistics, disease registries, health service use, air pollution monitors, satellite imaging, disease notifications, and other sources. Cause-specific death rates and cause fractions were calculated using the Cause of Death Ensemble model and spatiotemporal Gaussian process regression. Cause-specific deaths were adjusted to match the total all-cause deaths calculated as part of the GBD population, fertility, and mortality estimates. Deaths were multiplied by standard life expectancy at each age to calculate YLLs. A Bayesian meta-regression modelling tool, DisMod-MR 2.1, was used to ensure consistency between incidence, prevalence, remission, excess mortality, and cause-specific mortality for most causes. Prevalence estimates were multiplied by disability weights for mutually exclusive sequelae of diseases and injuries to calculate YLDs. We considered results in the context of the Socio-demographic Index (SDI), a composite indicator of income per capita, years of schooling, and fertility rate in females younger than 25 years. Uncertainty intervals (UIs) were generated for every metric using the 25th and 975th ordered 1000 draw values of the posterior distribution. Findings: Global health has steadily improved over the past 30 years as measured by age-standardised DALY rates. After taking into account population growth and ageing, the absolute number of DALYs has remained stable. Since 2010, the pace of decline in global age-standardised DALY rates has accelerated in age groups younger than 50 years compared with the 1990–2010 time period, with the greatest annualised rate of decline occurring in the 0–9-year age group. Six infectious diseases were among the top ten causes of DALYs in children younger than 10 years in 2019: lower respiratory infections (ranked second), diarrhoeal diseases (third), malaria (fifth), meningitis (sixth), whooping cough (ninth), and sexually transmitted infections (which, in this age group, is fully accounted for by congenital syphilis; ranked tenth). In adolescents aged 10–24 years, three injury causes were among the top causes of DALYs: road injuries (ranked first), self-harm (third), and interpersonal violence (fifth). Five of the causes that were in the top ten for ages 10–24 years were also in the top ten in the 25–49-year age group: road injuries (ranked first), HIV/AIDS (second), low back pain (fourth), headache disorders (fifth), and depressive disorders (sixth). In 2019, ischaemic heart disease and stroke were the top-ranked causes of DALYs in both the 50–74-year and 75-years-and-older age groups. Since 1990, there has been a marked shift towards a greater proportion of burden due to YLDs from non-communicable diseases and injuries. In 2019, there were 11 countries where non-communicable disease and injury YLDs constituted more than half of all disease burden. Decreases in age-standardised DALY rates have accelerated over the past decade in countries at the lower end of the SDI range, while improvements have started to stagnate or even reverse in countries with higher SDI. Interpretation: As disability becomes an increasingly large component of disease burden and a larger component of health expenditure, greater research and developm nt investment is needed to identify new, more effective intervention strategies. With a rapidly ageing global population, the demands on health services to deal with disabling outcomes, which increase with age, will require policy makers to anticipate these changes. The mix of universal and more geographically specific influences on health reinforces the need for regular reporting on population health in detail and by underlying cause to help decision makers to identify success stories of disease control to emulate, as well as opportunities to improve. Funding: Bill & Melinda Gates Foundation. © 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licens